6197 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
aUILDI APPLICATION & PERMIT 6197
AD
tD -ELECTRICAL-PLUMBING-MECHANICALPLAN CHECK VALIDATION
ELECTRIC PERMIT FEE
cy PHONEA Rs LETS-SWITCHES-RECEP 5.00/1.00
oTING FIXTURES 5.00/1.00
I CTO APPLIANCES-RESIDENTIAL 4.00
PHO PANELS 5.00 DATE OF APPLICATION
AHCIUTOLT f SIGNS 6.00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER
uc.NO SIGNS TRANS. 3.00
ADD ESS ENc. SPECIAL CIRCUIT 5.00 PERMIT vnuOnnoN
ZIP EMP. METER OR POLE INS. 15.00 /� �✓
� n P I ssTs MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
D
o o LICENSED CONTRACTORS DECLARATION
ar u 1 hereby a0irm Ihld hum'lieensed under provisions of Chapter ISSUANCE DATE
ar n Iro un nL ng with S etlb)T7000)of Division 3 of the Business nJ
Q SLOG. ELECT. PLG. MECH.
I{a'o-J Si Lm`seonsi red IA nL¢ Nuis in mbcril o ❑ ❑ L�
%�/� ont
4¢ 'y w sr C•/ OWNI R QUILDI R DECLARATI N BUILDING PERMIT
a- 03: 1f' a MISC.- REFER TO ORD INFORMATION
a- 3 F I hvel+y afro 1h I ant exempt from IheC nm cors License
S VALUATION $/FT.
LL
04 Law lur tlu full Ing r a1u ny(Se 7031 S.Businessand I less ons PERMIT ISSUANCE 6.00
ar aa a�a Code A,demolish,r I l repair any s Ur sap rior to a mint t,Wleq
a o Ilnpons., applicr o,such
any moi structure,prior tot s r unt talsohat ELEC.CONTR. LIC.NO. ELEC.
LL !e[IUlre$IIIL'applilanl ft)r]tient pClmll t0 file Ir.vib'nL'd Still Cllle'l11�11:11 TOTAL PERMIT TO
wm he is licensed pursuant to the provisions of the Contractor's L1Cltllse
Fzr Lasme,us ror 9lcontmenCnd ) lh Seniors is exemftItHeori3u(the' i
Q Business and Professions Code)or that he is exempt Oction 70 and QTY. PLUMBING PERMIT FEE fES
� E o p
¢ Fo the
nyapor tantfor aAermit subjects
Any vappliolial'Scction 7031.5' STORIES TYPE CONSTR.
n 3 iO by any applicant for a Penni(subjects S5 applieanlYouc r penally
of not more than fire hundred dollars(S500).) f'�! I I I ALTER-DRAIN&VENT-WATER (EA.) 4.00 `
❑ 1,as owner of(he property,or my employees with wages us - BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044. Business and PlOfesimis DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Cnntmctor's License Law does not apply 10 an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.rLOOR AREA TOTALACREAGE
himself Or through his own employees,provided that such int prow- .
I ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 4.00
or improremntt is sold wilhin one year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA) 100 BUILDING USE
builder will have the burden of proving that he did not build or inn. . . .
- RES IND CON PB Omer
prow It,,purpose of sule.l. INDUSTRIAL WASTE INTER. 20-00
C) 1,as owner of the properly,am exclusively ionlmcting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(ties. 7044, [tribes, LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:'I he Cumractur's Lirense Law does not apply
In an owner of pn.Puny who builds or improves Iheroon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
onlmels fin such projects with a contraaorto licensed pursuant to
the Contrnaor's license Law. SEWER-SANITARY-STORM EA, 200ft/8.00 TRACT NO. PARCEL NO.
❑ I:uncxcmpt under Scc. ,B.&P.C.fur this WATER HEATER W/VENT 4.00
Hasan
Dw"cr Date WATER SYSTEM 4-00 ACC.DATE ACO.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby allifm That I bare a certificate of onsent to I4insure' ZONING ENG.SITE NO.
olxnificam tl Workers'Compensation h uran c,m certil icd
c>Py Ihcre ,Ub.0 L 66
policy No._ ompynY.
O Cl ,edified rop Icrcb ' nished. RE SPR INK ENERGY Tao
z Z s7/JCcrlificJ�Eopy s EI 'ilh fit inspection division.
O A......... MISC.- REFER TO ORD. Y ❑ N❑ v ❑ N❑
W CER I'IFIC 'rE Ol'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU 5 M
COPI ANSA HON NSURANCE PLO.CONTR. LIC.NO. PLG.
(Phis section need not be completed il' the Permit is for ono TOTAL Y❑ N❑ v E] N❑
Z
hundred dolh¢s(S 100)or Tess.)
U O 1 certify Him in tire performance of the work lin which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil is is.vued,1 shall not employ any person in any roomer so its lu
❑ beconm suhjec1 OR the WorkSR'Compensa Don Lawsof CrIfidnni,i
U a Dale Appli°ant ALTER OR ADD TO MECH. 4.00 BUILDING
} 0 NO'I'ICF. 10 AITLICASN: If,after making this Cerl11'icme of Ex-
F Z_ colption,you should become subject 10 the Workers'Contpmsa(ion APPLIANCE 4.00 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 IOSWCF.M.) 3.00
CONST BECTON LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE
I hereby affirm that (here is a construction lending agency for EXHAUST HOOD(WITH DUCT) yw-2.00
the performance of(he work for which this permit is issued(Sec. - ICROFILM
3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.(7) 4.00
Lender's Name HEATI NG UN IT(OVER 100,000 B.T.U.)7.50
Lender's Address LECTRIC
I certify that l have read this application and state(hal the above VENTILATION FAN (SINGLE) $ 'TOO
• inl'onnatice is correct. I agree to comply with all city and countyPLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby ationeee roperty tolivn5 ec this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL 3 /
above hereby wntioned property for inspection puity 1.. ✓
(Wc) agree to save, Indem ' and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against I`bililies d cots;ros(s and expenses which PERMIT IS ANCE �' 3.00 CONST.TAX
�j n'ay in :m w' Crue gai said City in consequence of the J ..�
1 em Ui o h enniL t C ONT. LIC.NO. MECH.
1
- DTA TOTAL
1 I ureof Applicant(Contractor ate
INSPECTORCOPY