9432 (3)' APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BAL4_POINT PEN ONLY
'-'
BUPL""DING PROJECT IDENTIFICATION PERMIT NUMBER
1
BUILDING & PERMIT
'
(N
ADDRESS
1 BUILDING - ELECTRICAL-PLUMBING-MECHANICAL n
4 3 Z
OW
PLAN CHECK VALIDATION
"AME
ON QTY. ELECTRIC PERMIT FEE
( .
CONTRA TOR$
i
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
/4= LID N LIGHTING FIXTURES 10.00/1.00
DONTRACTo s // r APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10,00 DATE OF APPLICATION
RRC ECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
C.No. SIGNS TRANS. 3.00
ADDRESS G j SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
EMP.METER OR POLE INS. E 20.00 _-
• ADonEssT Ly/Q/RG G� /LL�t/> MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
° R ZTEMP.POLE .•30.00
F
02 LICENSED CONTRACTORS DCLA ATION !� /
v u I hereby al firm that I am licensed under revisions of Chapter 9
Q 2 w y' p P j f / ISSUANCE DATE
w z 'w (commencing with Section 7000)of Divisionr3 of the Business and ` �-� BLDG. ELECT. PLG. MECH.
E. m z Professions Code,and my license is in full force and effect , ❑ ❑ ❑
( z o m - License Chun y.Q_Lic.Number f"/ , r� -
o z H w are Contractor
m f -a �/al f - / BUILDING PERMIT
a Ix w o OWNER-BUILDER DECLWlI4'16?6 INFORMATION
E
o a _ I hereby affirm that I ten cxclo t from the Contractor's License MISC.- REFER TO ORD
i u y Y a P VALUATION $/FT.
FLL0 J Law for the following reason(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
re 3 O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
R ° u ,requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a, w m m he is licensed pursuant to the provisions On tie Contractor's License
>
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
� �7 A/C J�CLL
jf i sr Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
a r the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONTRR,
n ; _ by any applicant for a permit subjects lite applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).1:
❑ 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 the work,and the,stnlemre Is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code: The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 s0.PT.FLOOR AREA TOTAL ACREAGE
himself through his own employees,provided that such improve-
memsare renot intended oroffered for sale.If,however,the building GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or Improvmnent Is sold within one year n1completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will[lave the burden of proving that he did not build of int- RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with 0 . 0 ❑ ❑ ❑
licensed contractors to construct the project(Sec. 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 for such-projects with a contractorts)licensed pursuant to
Ore Contractor's License Law. I SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lamcxcmptunder S,,-,B&P.C.for alis WATER HEATER W/VENT 6.00
lease.
Owner Date WATER SYSTEM 5.00
ACC.DATE I ACC.FILE NO.
WORK ERS'COMPENSA'I'[ON DEC�LA�R/ATTII pyy WATER TREATING EQUIP. 5.00
I hereby' c �cVftiH<Tcrr1'L*tns�R'IC"If-insure,
or a certific le of Workeri Compensation Insurance,ora certified ZONING ENG.SITE NO.
copy thereo (Sec.3800,Lab.C.Ir� "' " � � �
Policy No. Cmnpany�w�rp�,.-_q I„�8+�s_
Q r ❑ CcHified copy is hereby tunisF 'had.- - FIRE SPRINK ENERGY T-24
z Z ertified copy is filed with the city inspec on division.
- 2
. plicae ' - MISC.- REFER TO ORD. Y ❑ N❑ v ❑ :N❑
CC D CI 'I'IFICA'f li Olr FXEMPl7ON PROM WORKERS' PERMIT ISSUANCE 10.60 FLOOD ZONE A.L.U.D.
W > Ix COMPENSATION INSURANCE PLG,CONTR. LIC.N0. PLG. y❑ N❑ V ❑ N❑
CL Z (This section need not be completed if the permit is for one TOTAL
hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per. QTY t MECHANICAL PERMIT FEE FEE SUMMARY
LL I- not is issued:1 shall not employ any,person in any mannerso as to
Q L)become subject to the Workers'Compensalion Laws of California. BUILDING
Q. Dute Applicant ALTER OR ADD TO MECH. 5.00
} to NOTICE TO APPLICANT: If,after making this Certificate of nix-
. F Z engaion,you should become slbjecl to the Workers'Conl pensat ion APPLIANCE 5.00 PLAN CHECK.
provisions of the Labor Code, you must forthwith comply with FEE
U Such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTR UCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
tare 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 I0 VER 100,000 B.T,U.)9.50
Lender,Addmxs ELECTRIC
I certify that 1 have read this application and state that lire above VENTILATION FAN (SINGLE) 4.00
a
information correct. I agree to comply with all city and county PLUMBING
'^F ordinances and stale laws relating to building construction, and BOILER-OOMP(3 H.P.or 100,0008.T.1A) 6.00
I
hercby ve- euthoed representatives ol.on perp e'1. enter upon the97 BOILER-COMP (Over 100,000 BTU)BE�I.lEE SCT(4. MECHANICAL
abovrmentioneJ Property for inspection purposes.
(We),agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino a dost Iia 'lilies,judgments, costs and expenses which CONST.TAX
may in an way a roc against said City in consequence of the PERMIT ISSUANCE 10.00
gmnti this p it. MECH.CONT. LIC.NO. ME
�GY/4i�G 9�cY�/ 2738ZJ T 2 - TOTAL
g a ore pP u, t/ ontrac a
l INSPECTOR COPY - -