4191 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FI CATION PERMIT NUMBER
BUILDING A PLIC TION & PERMIT
ADD..ESa
� Zv� RI� Q •/ QL(f c BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 4191
OWNER$ \ PLAN CHECK VALIDATION
NALi _�I O L OCG\ 1 / S-� f� QTY. ELECTRIC PERMIT FEE
• r't r P ONE
CO
DA
E NT crops73 OUTLETS-SWITCHES-RECEP 5.00/1,00
yn �ny II
Vk ) (,, Y C'J'L,c.NO )' LIGHTING FIXTURES 5.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00 -
�13QIc, Crc.dH PANELS 5.00 DATE OF APPLICATION
A�C HrI�ETECi (J�1 SIGNS 6QD PLAN CHECK FEE P.C.N0,
NV I �) eC IIQc.NZS0 1-7 S .SIGNS TRANS. 3.00
noonENG. PERMIT VALIDATION
Ess * SPECIALCIRCUIT5.00
3 NlQ LCA U*22 TEMP.
METER OR POLE INS. 15.00
ISI MIAPPLICANTS `fes ^�K MOTORS SEE FEE SCH.
DItJ Q ��:�r' {JI l� SERVICE CHANGE 10.00
o ¢ z
FOo LICENSED CONTRACTORS DF;;CLARATION ZO 'Ilr 1 Qk-v U,
Su U I hereby affirm that 1 am licensed under pmvi,iim..of Chapter 9 ISSUANCE DATE
w< m (co.nnu•mmng writ Section 7000)of Division 3 of t`hre Ilusiness and BLDG. EC PLG. MECH.
H w z Professions Cori,m1d license is in full to �ie'f"' ❑ ❑ ❑
z o w - Licens I s r L� Lit.Number F
0 z °w Date $t Contmctor fes- A -
¢ y s v BUILDING PERMIT
OWNER-BUILDER DECLARATION INFORMATION
Go ds " MISC.- REFER TO ORD
3 u ti I hereby affirm Contract.,*,I um exempt Gore the Contors I,icens, _ - VALUATION $)FT.
F ¢ o j Law for the following reason.(Sec.7031.5.business and Professions PERMIT ISSUANCE 6.00
Code:Anydity orcounty which requires a permit to construct.alter. EL D,DDNTR. LIC.NO-
¢ 2 a o improve,demolish,or repair any structure,prior to its issuance,also ELEC.
C ¢ requires the applicant fur such permit to file i signed stalcmem thin 1� e C,� IL TOTAL PERMIT'TO
wo, he is licensed pursuant to Ole provisions of tire Contractor's License l•
Ezr Law(Chapter 9(col Bing with Section 7000)of Division 3 efthe
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ r oo the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
aim by any applicant for a permit subjects the applicant to a civil penaltyALTER-DRAIN&VENT-WATER (EA.) 4.00
of not"tore than five hundred dollar,(S5000.):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2,00 OCC.GROUP RES.UNITS
their sole coniptu,alion,will no the work,and the structure is not
intended or offered for sale.(Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 4.00
Code:The Contractor's License Law does not apply to an owner of
Property who builds or Improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO,FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees.Provided limit such improve.
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
Or Improvement is sold within one year of completion, Out owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the harden of proving that he did not build or Int-
provcforpurpos,ofsae')' INDUSTRIAL WASTE INTER2000 RES IND CON PR other
❑ 1,as owner of the property,am cxch . .
tsivcly contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044.Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Prolessiuns Code:'f he Contractor's License Law docs not apply
to an owner of property who builds or improves Iheaon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts torsuelt projects with a cuntructor(s)l ceased pursuant to
the Conlr,tor's Liccrec Law. SEWER-SANITARY-STORM EA. 200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under See ,IS.&P.C.for this WATER HEATER W/VENT 4.00
reason
Date Ow'acr WATER SYSTEM 4.00 ACCOATE ACC FILE NO.
i
WORM RS'COMPISNSA1 ION'DECLARATION WATER TREATING EQUIP. 4.00
I hereby alts.. Ihut I hove a'Frilicale if consent to sd f-insure 2DNING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy t1' rD h�:��p.,.j$ Lab.CJ1 1
Policy N".1'(/V1.,0 , Pary �-G'-•�y lTn
Q CerNl copy n he by'lar Kd. FIRE SPRINK ENERGY T-24
Z Z Certs 1- fled w' t7� t��nspe,timl divisi r,
O APplirml I r� MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
� T CERT I P ICI1'17 OP I:it nt 1'I'IO N P ROM WO R K Ii RS' PERMIT ISSUANCE 6.00 FLOOD ZONE A,L.U.C.
DJ > C011PENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. v❑ N❑ v ❑ N❑
CL O This section recd not be completed if the permit is for one TOTAL
D Z hundred dollars IS 100)or less.(
U O_ I certify that In the performmnce o1'tine work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
UL F mit is issued I shall nut nuDloy any Pvr,ori in any mann,,so as Io
U become subject tD the WorkerG Compensmion Laws of California.
UJ Dam APPI'e'?"t ALTER OR ADD TO MECH. 4,00 BUILDING
} m NOTICE TO APPLICAN'1: If,after making this Certificate of lis-
F-. ? emption,you should become subject In the Work,,,Conlpcnsalio" APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you nmm forthwith comply will, FEE
U such provisions or t11is m
pennit skull be accrued revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONS]'RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMICFEE .-e
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this pennit is issued See. MICROFILM
3097,Ch'.C.1, HEATING UNIT(TO 100,000 B.T.U.) 4.00 A
Lender's Nome--f�_Z HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address-ISL ELECTRIC
I certify' that l have read thn.foliaatim,and stat,that the above VENTILATION FAN (SINGLE) 3.00
• info..nation is correct. I agree to to n.ply will,all cit}'ami counfy PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.or100,000B.T.U.) 4.00
hereby eulhorire representatives of this city Inenter Upon the BOILER-COMP (Over 100,000 BTW SEE FEE SCH. MECHANICAL
above...,entiorcd property for inspection purposes,
(We) agree to save, ndmnlify and keep hanWasx the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgnuents, costs anA expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may i any way a4crue uga'rt t mid City' in consequence of tine
gmFri g f this per fit. � � � MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Sig alone of ApPlica /C ntractur I).nc
INSPECTOR COPY
I 1