6810 (2) -APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT ADDRESS'S 6810
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL '
O [ PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
. veoN
NAM[RACTo s UTLETS-SWITCHES-RECEP 5.00/1.00 2,41
LIGHTING FIXTURES 5.00/1.00
ACTORS
ADDRESS PPLIANCES-RESIDENTIAL 4.00
ADOREZo ��/
�- PRONE PANELS 5.00 DATE OF APPLICATION
OR RCHrtEtT SIGNS 6,00 PLAN CHECK FEE P.C.NO.
O
ENGINEER
LIC.rv0. SIGNS TRANS. 3.00
ARCHEORR ENG.SS SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
AICANT's MOTORS SEE FEE SCR. S
ADMomaEss
/// s r x. SERVICE CHANGE 10.00 •qL mfr
o o LICENSED CONTRACTORS DECLARATION / 4/ /v
a v U I herehy affirm that I am licensed under previsions of Chapter 9 s M �- ISSUANCE DATE
2 a (cimim,ocing with Section 7000)of Division 3 of the Busineti and a - BLDG- ELECT. PLG. MECH.
wDi Professions Code,and my license is in full force and effect F1Elz O m - License Cla s Lic.Number o6o7 4»Y9 ,,//
4 ° Date Contractor /q - A y-..>•a's' /-.f F'P O(
¢ Y ¢ a OWNER-BUILDER DECLARA'f10N /3 /r
If
o BUILDING PERMIT
oa " MISC.- REFER TO ORD INFORMATION
Z
; y I hereby a(fir,n that I sen exempt from the Contractor's License
F a. oj Law for the following reason.(Sec.703 1.5,Business and Protessions PERMIT ISSUANCE 600 VALUATION $/FT.
m � Code:Any.city or county which requiresa permit toconstruct alter,
QQ Q 0O improve,demolish,or repair any structure,prior to its issuance',also ELEC.CONTR. LIC.NQ ELEC. 9�3
O ¢ requires the applicant for such permit to file signed statement that - TOTAL / PERMIT TO
is °' he is licensed pursuant to the provisions of the Contractor's License
F z i Law(Chapter 9(commencing with Section 7000)of Division 3 of the �Y.6C7
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ H o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
aim by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER IEA.) 4.00
of not more than five hundred dollars($5001.):
❑ 1,as owner of the property,Or my employees will, 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(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:'rhe 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 SO.FT.FLOOR AREA TOTAL ACREAGE
.
himself are not hrongit
ownemployees,for sale.11,ho That such improve- GAS-EA.SYSTEM-1 4.00
mm�b are not intended or emplo for sale.IL however,th bei Wing
or impmvenm,nt is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with E] E] C3 E] ❑
IIDen.ced contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. ' 5.00 ASSESSORS PARCEL NO.
and Nofessions Code:'I'he Contractor's License Law does net 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 contractors)licensed pursuant to
the Contractor's license Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lamexemptunder Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Ownar Dat, WATER SYSTEM 4.00 Acc.DATE ACC.FILE NO.
WORK HRS'COMPI:NSA'rION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that 1 have a c,Nhicate of consent to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(See3800,Lah:.L
Policy No. Company A�-+stVLQ LIT _
O ❑ Certified copy is hereby f rokle,c]. _e{7J •Qp/� FIRE SPRINK ENERGY T 24
Z Z *F certified y. is fie lh the city I ree}imwAlesion. MISC.- REFER TO ORD.
Q )1 Dplieenr� V ❑ N❑ V ❑ N❑
CCCIi
T RIPICA'lli OP 1: I[.M 1'110 1 W( KERS'
PERMIT ISSUANCE 6.00 FLOODZONE A.L.U.C.
' l
LU > CO.MPFNSA1']ON IN RANCE PLG,CONTE. LIC.NO. PLG, Y[3N E] Y ❑ IN❑
CL Z ('Phis 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, OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL l- mil is issued,I shall not employ any person in any manner so as to
V hecomesuhpact to the Workers'Compensation Laws of Culit'eouiu.
0 0- DateApplicant ALTER OR ADD TO MECH. 4.00 BUILDING
>_ to NOTICI? TO APPLICANT: If,after making this Certificate of Ex- --
F2 empligo,you should become subject to the Workers'Compensation 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 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=CF.M.) 5.00 l SEISMIC FEE
I hereby affirm Omm there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance rif the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's ddr H EATING UNIT(OV ER 100,000 B.T,U.)7.50
Lenders AAddress ELECTRIC 7o(
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relaling to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over ioo,o00 BTUI SEE FEE SCR. MECHANICAL
above-n®ntioned 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 CONST.TAX
may in ny way ue against said City in consequence of the PERMIT ISSUANCE 3.00
gmnli (this pc nit MECH.CONT. LIC.NO. MECH,
TOTAL TOTAL
S alure efA pli ant/C cto Date
INSPECTOR COPY