6109 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 6109
ADONE55 S�
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNEH'5 PLAN CHECK VALIDATION
NAME TY. ELECTRIC PERMIT FEE
• LC PRDN 53AW
-
corvrHAcroRs UTLETS-SWITCHES-RECEP 5.00/1.00
NA ` ''r ,/
.. 44_ C.No. 71 LIGHTING FIXTURES 5.00/1.00
rONrRACTORS APPLIANCES-RESIDENTIAL 4.00
ADD less _
.P^
PANELS S:OOP�E DATE OF APPLICATION
ARCHITECTSIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
nooeEss ENG, .00 CIRCUIT 5.0Q PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
ADOrIES rs ,E���� (/T MOTORS SEE FEE SCH. J
ADOIIE55 GC/
b SERVICE CHANGE 10.00 711ld �
Dec . LICENSI'DCON'f RACfORS DECLARATION Os'
a in w I hereby'off irin Hot I alit liceosed under provisionsof Chapter 9 ISSUANCE DATE
<H 1 omm being will,Section 7000)of1� ism of the Business and _ BLDG. ELECT. PLG. MECH.
I n ic.-.I ms Codc.yyy���l i nsu. t tl 11(or- K $1 ..�
O i H o L 1.11.4 l,bcr/� / r� ❑ ❑ ❑
r wdo c� Contractor
m o a
OWNER-BUILDER D[CLA RATION r BUILDING PERMIT
ai INFORMATION
K
0 1 herchy affirbh Ih I I am v.,CH,l from the C.moctoh License MISC.- REFER TO ORD
u VALUATION $/FT.
F t. oa Law lin lire following«asun.(Set.7031,5,Businecl and Professions PERMIT ISSUANCE 6.00
Code:Any city or callow which mquireso probit to conslr,I (Ilea
2improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
is E a¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w he is licenwd pursuant to the provisions of the Contractor's License
zi Law(Chapter 9(commencing with Section 7000)of Division 3 of tire
- a 1lusiness and 1'rofessions Code)or that he is exen.pt therefrom and QTY. PLUMBING PERMIT FEE � K-�Q/m
r m the has is for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
La ; � by any applicant for a permit subjects the applicant o a civil penally
nl bol more than five hundred dollars(5500).1: ALTER-DRAIN&VENT-WATER (EA.) 4.00
❑ 1,as owner of the property.or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sale Compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Old,'I'lie Co^tmclor's Liccesc Law does nal apply to an owner i
properly who builds or Improves thereon,and wlr,does such work FIXTURES-PER TRAP 4.00 SQ FT.FLOOR AREA TOTALACREAGE
• himself'or through Iris own employees,provided that such In'
prove-
^tents are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4(EA.) 100 BUILDING USE huildcr will have the burden of po vmg that he did not build or in, . . .
RE IND CON PB One,prove for'u"..of'salc.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the properly,mb exclusively contracting with _..
licensed contractors to construct the projem(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Prob,inns Care: I he Commclor's License Luw Aoes bol apply-
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OV ER 5(EA.) 1.00 _
conlmetsfor such projects with a contractions)licensed pursuant"
the G ntractrc License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑"
4 anti cxclmpl under See. ,B.&P.C.for this WATER HEATER W/VENT 400 T
rcazod
I)
Owner -i Date WATER SYSTEM 4.00 s ACC.DATE ACC.FILE NO.
WORK ERS'COAIPENSA'I']ON DECLARATION WATER TREATING EQUIP. 4.00
";;_-],IIq,vby;ll that I have a ce,lificrueofic o ns m tg II incl re ..�. -E+s._- ZONING ; ENG.SITE NO.
or a euofieat o1�KyCdn�rk�urs Com Pclrsallon Insurance,or a cerli le 4
O ❑ Certified copy is hereby l urnhsher FIRE SPRINK ENERGY T-24
Z Z Certified '-is* with a.,ily-'nsp 'lion divisat. ..
O Aplwm MISC. REFER TO ORD. TE] N r%v � N�
CC N Off: I'1:CA'I'E( F F.XEMPI'ION F M WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE "'A.L.U,C.
LL > i COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
O (This Section need not be completed if the permit is liir ane TOTAL V N� V NEI
Z hmtdood dollars($100)or less,)
U O 1 certify that in the performance of the.work It,,which this par' QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mil is issued,1 shall not employ nnY person in a^y nernner so as ID
Ow m
hecontcsubjecl to Workers'Copunsation Lawsof California.
M Dun• Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} 0NO'T'ICE'I'O APPLICANT, If,after making this Certificate of Ex, o��ssro�
F Z emptian,you should become wbject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
pmvislons of the Labor Code, you must hhtlhwith Comply with FEE
U sud,Provisions or this permit,hull be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10DWC.F.M.) 5.00 SEISMIC FEE .50
I hereby affirm that there is a construction lending agency far EXHAUST HOOD (WITH DUCT) 2.00
the Performance, the work fur which this permit is issued(Sec. MICROFILM
3097,Cor C.I HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I(rave read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
Ordinances and state laws relating to building construction, and BOILER-COMP 13 H.P.or 100,000 B.T.U.) 4.00
hereby eullanrc representatives of this city to enter upon the BOILERCOMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
ubovomemoned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may yl, way ace gmnst Said City in consequence of the PERMIT ISSUANCE 3.00
gra toga the per 1. MECH.CONT. LIC.NO, MECH. A
TOTAL TOTAL
igbuturcof Applicant/Contractor V D5tS
INSPECTOR COPY