8393 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDINGAPPLICATION & PERMIT \/��
ADDRESSS�Z C/� / `1-0 BUILDING -ELECTRICAL-PLUMBING-MECHANICAL $3l'3
OWNER'S ✓ PLAN CHECK VALIDATION
t "AME cLQK PmON1M_1qA9
QTY. ELECTRIC PERMIT ' FEE
CONTRACTORS
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
I, p �OA�jl.sec.rvo. 77�.�JI, LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00 I
/ ADDRESS /' C ,fp_
R �
(/ (� PRpNE�J�-y-�I� PANELS 10.00 �� DATE OF APPLICATION
.ARCHITECTPANELS (OVER 200 AMP) 20,00 PLAN CHECK
OR FEE P.C.NO.
ENGINEER
LIC.No, SIGNS TRANS. 3.00 �.
ARCH.
RENG.
SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ADDRESSZIP EMP.METER OR POLE INS. 20.00
ADDRESNr'$ MOTORS SEE FEE SCH.
SERVICE CHANGE - 20.00
w 0 2 LICENSED CON TRACTORS DECLARATION TEMP.POLE 30.00
U u I hereby affirm that I am licensed under provisions of Chapter') ISSUANCE DATE
na w (commencing with Section 7000)of Division 3 of the Business and BLDG., ELECT. I PLG. MECH.
H y i Professions Cod , nd my license is in full fore m e41' t {
z o w- License Class_Lic.Number��
9 z F � Dulc (y F� Contractor , L- �
H b, BUILDING PERMIT
Q w ¢ OWNER-BUILDER DECLARATION J INFORMATION
4 U MISC.- REFER TO ORD
w LL y I hereby affirm that I am exempt from the Contractor's License VALUATION 8/FT.
F LLOa Law for the following reason.(Sec.7031.5,Businessand l'rol'cssions PERMIT ISSUANCE 10.00
rA � Code:Any city or county which requires a permit to construct,alter, 0��o
¢ < 0 improve,demolish,or repair any structure,prior to its issuan e.also ELEC.CONTR. LIC.NO. ELEC. �/
DLL ..quires the applicant In,such pem,it to file a signed statement thal TOTAL O PERMIT TO
n w m he is licensed pursuant to lire provisions of the Contractors License
Hza Law(Chapter 9(commencing with Section 7000)of Division 3 nl'the
Business and Professions Code)or that he is exempt therefrom and GTY. PLUMBING PERMIT FEE
¢ fO the basis forthealleged exemption.Any violation of Seclion7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant ton civil penally ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
0 I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is riot CL OCC.GROUP RES.UNITS
intended or Offered for sale (Sec. 7044, Business and Pr fessiovs DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Conhacmr's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO FT.FLOOR AREA TOTAL ACREAGE
•
himselfornot hrough
ownemned fors, 1c.If,withal such improve- GAS-EA.SYSTEM-1 INC. OUTLETS 6.00
mems are not intended orthin on for sales If,however•,the but Wing A51
builder l
or improvement is sold within one year of completion the Owner GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or inl-
RES IND CON PB Other
prove 1,aso neer of sole.). INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
❑ d as owner of the property,con project
(Se . 7044, ing with
licensed contractors to construct the project(Sea 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's s License Law does not apply 5
toan contrOwner of property who buildsor trimprovesthereon,andwlto LAWN SPRINKLERS-OVER 5IEA.1 1.00 36L 3V /eL
(lie Contractor's
su License
Lwithacommdods)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 /-
the ConUador's License Law. TRACT NO. PARCEL NO.
❑ [am exempt under Sec.-,B.&P.C.for this WATER HEATER W/V ENT 6.00
son
Owner Date WATER SYSTEM 5.00
ACG.GATE ACC.FILE NO.
WORKERS'COMPI7NSA'I'1ON DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a eartil'icme Of consent to sell-i.,um, u
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy that, ( See.3 00,Lab.C.) u / fq-.N o)
Policy NOi�Ry�Company' � Ad%-�E y7 .
O ❑ CmtrOe c'D_y_i,here4y fu rn rs cod/ FIRE SPRINK ENERGY T 24
r z Z ❑ Certified pe Is fl , 1 m city inspection division.
2-�tppicanU /�/ - MISC- REFER TO ORD. Y❑ N❑ Y ❑ N❑
F to / O r NS[ PERMIT ISSUANCE
ChiR' MCATF OI*EXEMPTION I7ROMW 1.ER5' FLOOD ZONE A.L.U.C.
W COMPENSATION INSURANC PLG.CONTR. LIC.N0. PLG.
CL aZ (This section need not be completed if th permit Is for one TOTAL "� Y❑ N❑ Y❑ N❑
hundred dollars(S 100)or less.)
U 0 1 c,llfy that in the performance of the work for whirl,this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil is issued, 1 shall not employ any pemon in any manner so as to
0 0 become subject to the Workers'Conipensalion Laws of Culiton,in.
Dale Applicant BUILDING ./' Sp N
t a ALTER OR ADD TO MECH. 5.00 T
} 0 NO1'ICE'1'0 APPLICANT: If,after making this Certificate of Ex-
i~ Z vnplum,you should become Subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
Provisions of the Labor Code, you most forthwith comply with FEE
CJ such provisions or this permit slmll be deemed revoked. AIR HANDLING UNIT(TO 10J)00 C.F.14) 4.00 C
CONSTRUCTION LENDING AGENCY AIR H,{NDLING UNIT(OVER IO)000CF.M.) 6.00 SEISMIC FEE d G
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 .
30• performance of the work I,or which this permit is issued(Sec. MICROFILM
HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC 01/
I certify Unit l havemad Uhisappheation and slate 0mt the above -VENTILATION FAN (SINGLE) 4.00
mourrnmion is correct. I agree to comply with all city and county PLUMBING ll�
Ordinances and state laws relating In building construction, and
BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 �a2
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL t2
above-mentioned property for inspection purposes. --
(We) agree to save, indemnify and keep harmless Ore City of MI SIC.- ° REFER TO ORD.
Cupertino against liabilities,judg ants, costs and expenses which CONST.TAX
may in any way a55cru against aid City in consequence of the PERMIT ISSUANCE 168 �(
grim it,Of at. MECH.CONT, LIC.NO. MECH.
TOTAL /J`w TOTAL Q Z /i
Sig nald Apj
- V INSPECTOR COPY