6004 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FI CATION PERMIT NUMBER
BUILDING rJ // ZAPPLICATION & PERMIT
T AD�SnSfAh4�irl D4 I` C° T - 6004
a� BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAM J A/ / OTY. ELECTRIC PERMIT FEE
'. /1/• �� PHONE�73-lS276 r
CONTRACTOR'S
N��"'E OUTLETS-SWITCHES-RECEP 5.00/1.00
fY L( LIGHTING FIXTURES 5.00/1.00 Z'
CONTRACTOR DDRESS - APPLIANCES-RESIDENTIAL 4,00
Jl/ /p(4AtWeiS I-ONE37 -YlS03 PANELS 5.00 DATE OF APPLICATION
ARCHITECTSIGN$ B.DD PLAN CHECK FEE P.C.NO.
OR
ENGINEER
•-- LIC.No. SIGNS TRANS. 3.00
ADDRESS sNc. SPECIAL CIRCUIT- 5.00 vEEMlr VALIDATION
ZIP EMP.METER OR,POLE INS. 15.00
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00 '/ G
o o LICENSIi1)CONI RACTORS DECLARATION
a o u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w a i (commencing wilh'SirEtbr1�7000)of Division 3 n(the Business and BLDG. EL EC PLG MECH.
F m Z' Professions Code,a d m lie use is in full frece-and of ct IL.11�/fty\ ❑
z o err License Class D Cia Number 1
4�.�w I Dater Contractor
-¢ y f ���,��--___� BUILDINGPERMIT
¢ ¢ w ¢ OWNER-BUILDER DECLARATION
a 0 a " f INFORMATION
X 1 hereby aft irnl that I am exempt from t ntractor's License MISC.- REFER TO ORD
3 u VALUATION S/FT.
F a o j Law for the following reason.(Sec.7031.541M&Mud Professions PERMIT ISSUANCE 6.00
� 14�E Code:Any city or county which requires a permit to construct,alter, ELEC.CONTE. - LIG NO. /
¢ Q ¢O improve,demolish,or repair any structure,prior to its issuance,also ELEC. / e �t
0 LL requires the applieanl for Such pormil to file a signed slalemcnl Thal TOTAL PE IT TO
a w m Ile is licensed pursuant to be
provisions of the Contrstor's Liccnsc �}�
La z i Law fChliptcr')(armmmining with Section The Cof DivisionLooter qpO /OA/4" Y
H. - a Business and Professions Code)or that he iSexempt therefnnn:rod QTY. PLUMBING PERMIT FEE rfF/
¢ 4¢- Dp the basis lilt the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
ate _ by any appliemit for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(S500)J:
❑ I,us owner of the property,or To,employees with wages as 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(See. 7044, Business and Prufessimrs DRAINS-FLOOR,ROOF,AREA,COND. 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 Sa FT.FLOOR AREA TOTALACREAGE
• himself or through his own employees,provided that such improve. -
or imp
are not intended or offered for salt.If,however,the building
GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
or unem is sold within one year of completion,the owner- III
GAS-EASYSTEM-OVER 4(EA) 100 BUILDING USE
builderlder wwill have Om burden of proving that he did not build or im- . . .
RE IND CON PB Omer
Prove 1. purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,he exclusively contracting with ❑ ❑ ❑ ❑
licensed canons od to construct the project(Sec.7044.Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions property
Contractor's License Law Joel nal apply
prop
loan owner of property who ha ecus or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 \,
Contents Contractor's
such License
with a comrac[otls)licensed pursuant to RC
the Contractors License law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I Ynl exempt under Sec.-,BAP.C.lbr this WATER HEATER W/VENT 4,00
reason
Own" Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKI:RS'COMPENSA'[ION DECLARA'T'ION WATER TREATING EQUIP. 4.00
I hereby:dOrn Him I have a certificate of"mocnt to cIf-insum, ZONING
or a certificate of Workers Compensation Insurance,or a certified ENG.SITE NO.
copy(hcrcol'(See 3800,Lab.C.). /
Policy No�14J4:;1omPauy 5%r/P FU AICA
O ❑ Certified copy is hereby furnished- FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is tiled wilt the sty irype"iuq division. MISC.- REFER TO ORD. 1.
Q Applicant -Ina-c_� aivrOS Y❑. N❑ Y ❑ N❑
CC N CERI'IFICA'1'1;017 EXI MPyTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.Lu.C.
IL > _ COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG. O
CL-0 1'I Ili, Section need not be completed if the permit is for one TOTAL Y E] N❑ Y❑ N❑
hundred dollars IS 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 F mil is issued,I strait not employ any person in any manner so as to
OU luconle subject to the Workers'Compensation Laws of Califnnria.
w Date Applicant BUILDING
a !p ALTER OR ADD TO MECH. 4.00
} w NOTICE TO AI'11LILANT: If,after making this Certificate of Ex-
Z
trillium,you should become subject In the Woden'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of fire Labor Code, you must forthwith comply with FEE
U such provisions or(]its permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONS'I'RUCI ION LENDING AGENCY AIR HANDLING UNIT(OVER IOSMC.F.M.) 5.00 SEISMIC FEE
.I
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the perlorc u n v of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC 7
1 certify that I have read this application and state that O¢above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING U
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.or100,000B.T.U.) 4.00
1,Itchy authorize representatives of this city,to enter upon the BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property 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 which PERMIT ISSUANCE 3.00 CONST.TAX
ny 'n any way accrue against Said City in cxnsequence of(he
gr' li gof this permit _ MECH.CONT. LIC.NO.I 4a4 TOTAL
TOTAL //(�3y
Slip ore o Applit nt Contractor ate
sr' _ INSPECTOR COPY '