8680 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
anORE55
680 A A
BUILDING-ELECTRICAL-PLUMBING -MECHANICAL vn}U(U
OWNER'$ PLAN CHECK VALIDATION
'7 01A rvaME QTY ELECTRIC PERMIT FEE
r • ONE
HnmeRA R UTLETS-SWITCHES-RECEP 10.0011.00
LIc.No LIGHTING FIXTURES 10.00/1.00
ADDRESS
r
coni Orsi APPLIANCES-RESIDENTIAL 4.00
F
S F44 S111ONE PANELS 10,00 DATE OF APPLICATION
onncwi ci-ps PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO,
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH,OR ADDRESS ENG. SPECIAL CIRCUIT S.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCH,
SERVICECHANGE 20.00cy
pp
0 9 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
iw I hereby affirm that I am licensed under provisions of Chapter ISSUANCE DATE
y 4 'w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
0 ti z Professions Cod• and r y license is in full Ioru A
z O m - Datenac Class Lin.Numbs 1 L'9 7
0 r D Date m CuntraCtur
a m 5 a Il I UILDF:R DECLAR nON BUILDING PERMIT
a IS IS INFORMATION
X 3 LL s- I hereby atfirn hat I am exempt from the Contractor's License MISC.- _ REFER TO ORD
L oaa Lawforlhe following reason. 703 L5.Business and Professions PERMIT ISSUANCE 10.00 VALUATION g/FT.
�- - -' Code:Any city orcounty which requires a permit to construct,after,
le 6 G 0 improve,derfulislt,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
a wo K requires the applicant for such pefmit to file a signed statement that TOTAL PERMIT TO
as Ihe is licensed pursuant to the provisions of the Contractor's License
r z a Law.(Chapter 9(commencing with Sect inn 7000)of Division 3 of the `�4-d
x o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE / C,_
IS I$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
T ; - by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(S500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do lite work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thercOn,and who does SIICII work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended oroffered for sale.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
or improvement is sold within one year of completionthe owner- GAS EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). RES IND CON PB Due,
❑ 1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
licensed contractors rn construct the project(Sem 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code.The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts Ivy such projects with a contractors)licensed Pumuunt to
the Contractor'sLicense Law. SEWER-SANITARY-STORMEA.200ft/10.00 TRACT NO, PARCEL NO.
.❑ 1 am exempt under Sec.-.BARC.for this WATER HEATER W/VENT 6.00
reasongeg
Owner Date - WATER-SYSTEM 5.00 ACGDATE ACC.FILE NO,
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. \5.00
I hereby uI my that I have a cert ifieale of consent to"IfwL
r a certificate of Wor r'[omperlsation Insurance,or a certified ZONING ENG.SITE NO.
We a
n ICY V o a, r7.eo
O Certified copy isberet,Filed fu lilt t _ d FIRESPRINK ENERGY LI4
Z Z ❑//Certified copy is flet with the city inspection division. MISC. REFER TO ORD.
F Q ApVI'Camt Y ❑ N❑ Y❑ N❑
� N
CER'1'I FICAq)F EXON PROM WORKERS' PERMITJSSUANCE s _a10.00 . FLOOD ZONE a.L.u.c.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. I PLG:
CL O (This sectiun need not be completed if the permit is for one - TOTAL Y❑ N❑ Y ❑ N❑
D Z hundred d0lms(S 100)or less.)
-U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner so as to
O U become subject to the Workers'Compensation Laws of California. 1
a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} rA NONCE'10 APPI.ICAN'f: IL after making this Certificalc of lirc-
F Z_ emption,you should become subject In the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency(or EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lcndcr's Na'dress� ELECTRIC
I certify that I have read this application and slate Thal tte above VENTILATION FAN (SINGLE) 4.00
ordinances n correct I agree to comply with all city ad count, BOILER-COMP13 H.P,or 100,000 B.T.U.) 6.00 PLUMBING ,o0
ordinances and stale laws relating to building construction and
hereby authorize representatives tarries of this arty to em er upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
hereby
above-mentioned property for tativ spot this
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 in any way vruu against said City in cronsalumme I(the PERMIT ISSUANCE 10.00
gra ling of tills per MECH.CONT. LIC.NO. MECH.
OTAL TOTAL
S' •e A I ' o t o Dac /D.�
INSPECTOR COPY
t