7107\ APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
\ BU I LOING PROJECT I DENTIFICATIO 4 PERMIT NUMBER &'
BOILOING , APPLICATION & PERMIT '
ADDRESS 7
/A.?T BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 7 07
E 'S I��/✓✓ PLAN CHECK VALIDATION
& � PHONE
CITY. ELECTRIC PERMIT FEE
•� �
rvTRACTGR's OUTLETS-SWITCHES-RECEP 5.00/1.00
NAME r
_ l, uC.NO 3j267,r. LIGHTING FIXTURES 5.00/1.00 -
ry cTon'sI I APPLIANCES-RESIDENTIAL 4.00
tAluciorECT'
ooREss
T PHONE Z PANELS 5.00 DATE OF APPLICATION
SIGNS6.00PLAN CHECK FEE P.C.NO.
R ^^NGINEER eCaNoSIGNS TRANS. 3.00DDR,SS EN PERMIT-V LIDATI
ADDRESS SPECIAL CIRCUIT 5.00
d ZIP TEMP.METER OR POLE INS. 15.00
APPLICANT
ADDRESS
MOTORS SEE FEE SCH.
J A
SERVICE CHANGE 10.00
w O o t LICENSED CON"IRACTORS DECLARATION
ee G o v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with' "ion 7000)of Division 3 of the Business and
Q vAi BL ELECT. PLG. MEC
I_-z P nl'essions Code, illy license is in full fort• ,yDy�
-z O{"n - License Cla Lia Nmnber NI
o o Uafc� Contractor r - 'Y
Y � BUILDING PERMIT
w u WN;R-BUILDIiR DCCLAHA"I'1 INFORMATION
Aoa MISC.- REFER TO ORD
L S r I hereby allure that I am exempt from the Contractor's License
VALUATION SIFT_
a o 4 Law fur the city
or co reason.(Sec.7031.5,permit
Professions 6.00
PERMIT ISSUANCE
e, Code:Any mulish county whiny reqstructure,
u tune p rior 10 construct,,also
2 ¢ Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEG
e m T requires the applicant for such permit to file a signed Statement that TOTAL PERMIT TO "
m w be is licensed pursuant to the provisions of the Contractor's License
F z¢ Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 O Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
T H m lire basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant fire hundred dollars
thcapplicunuoacivil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more chat fora hundred dollars the applicant
❑ L,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 DccGROUP RE5 UNITS
their sole compensation,will do Ore work,and the structure i .not %
intended or pitered lir, Side(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 4.00 "
Code:The Contractor's License Law dos not apply to an owner of R3
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.PLOOR AREA TOTALACREAGE
himself or through his own employees,provided that,such improve
meats are nut intended Or offered In,sale,it,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00 / Or
or improvement is sold within one year of completion,the owner-
, builder will have the burden of proving that he did not build Or im- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
IND CON Pa ower
prove For purpose of sale"). - - INDUSTRIALWASTE INTER. 2000 E
i ❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
y. licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 1ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply _
C m an owner of property who u
builds r improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 3S '�`� �6 -p/j _
contracts for such projects with a contractors)licensed pursuant m
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ Iwo exempt under Sec.-,RAPC.for this WATER HEATER W/VENT 4.00
{
Owner Date WATER SYSTEM 4.00 ACC.DATT ACC.FILE NO.
- R(F wZp Rqg I: S'co l'IiN ZION DIiC1.n RA'noN WATER TREATING EQUIP. 4.00
hemby aTfl/m-IR]t I�fa a r le.1 consent to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certifeJ ENG.SITE NO.
copy thcrcnfBac 3800,LuhL.). � �
Polity No. Company
O ❑ CcrId`e,4S.pyishepebyfpm I
FIRESPRINK ENERGY T"24
%Z Z Certified cap, 's fled with Ole city inspection division. MISC.- REFER TO ORD.
_ O n11I I,, l _ Y ❑ . N❑ Y ❑ N❑
N CER IFIC EMPTION FROM WORKB S' PERMIT ISSUANCE 6.00 / PLOODZONE A.L.0 c.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. I Y❑ N❑ Y ❑ N El
)')'iris ucfidn need mol he completed if the permit-is for one IT
OTAL
hundred dollms(S 100)or less.)
U O _ 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in oily mmnmr m as to
OU Accomesubject to the Worke,s'Compmaation Laws of California.
y Date ApplicantALTER OR ADD TO MECH. 4,00 BUILDING
} N NO[ICE 'I'0 APPLICANT: 11,after making this Certificate of Ex-
� 2 eoption,you should become subject to file WorkeD'Conspenmtion APPLIANCE 4.00 PLAN CHECK
provisions of the Ichor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10SMC.F.M.) 3.00
CONSTRUCfION LENDING AGENCY AIR HANDLING UNIT(OVER IOAOOC.F.M.) 5.00 SEISMIC FEE
I hereby affirm [flat there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance othe work for w "It thix permit E issu (Sec. MICROFILM
3097.Civ.C.). HEATING UNIT(TO 100,000 B,T.U.) 4.00
Lender's NameHEATING UNIT(OVER 100,000 B.T.U.)7.50
fry f0eif;
Lenders Address ELECTRIC
I certify that I have lea Olisappliclown and state That the above VENTILATION FAN (SINGLE) 3.00 A�
• information is correct. I agree to comply with all city and county PLUMBING v(!
ordinances and stale laws relating to building construction, and BOILER-COW13 H.P.or 100,000 B.T.U.) 4.00 r
hereby awhon,c representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly 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 whichCONST.TAX
may in any way accrue against mid City in consequence of the PERMIT ISSUANCE 3.00
grams this peml�j ` ECB.CONT. LIC.NO. MECH.
Sig TOTAy / TOTAL
St of Applicant/Con(mclor IDae I
1 INSPECTOR COPY