7068 (2) j�APPLICANT TO TILL IN.IN� ORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
%ADDOESS
DING PROJECT IDENTIFICATIONPERMIT rvumBER
APPLICATION & PERMIT
a/��� 1, LDING -ELECTRICAL-PLUMBING-MECHANICAL7068�/ PLAN CHECK VALIDATIONQTY. ELECTRIC PERMIT FEE
s ^ OUTLETS-SWITCHES-RECER, X5.00/1.00 1 •1
�t.NO, LIGHTING FIXTURES 5.00/1.00'S
r�I ' •�/ POOR ss _PPLIANCES-RESIDENTIAL 4.00 -
Y II /
'PANELS 5.00 .1 DATE OF APPLICATION
AORC TCT SIGNS 6.00 PLAN CHECK FEE ,.C.NO.
r. ENGINEER SIGNSTRANS. 3.00
/ ARGH.oR ENa SPECIALCIRCUIT 5,00 PERMIT VALIDATION
' ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00 /
APPLICANTS MOTORS SEE FEE SCH.
DORE
Ass G
SERVICE CHANGE 10.00
_ o o LICIiN$GU CON'I'RACfORS D[CLARATION I
¢ o U I hereby affirm that I am licensed under provislm¢of Chapter 9, SSUANCE DATE
t oHi su N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MEfH,
F y z professions Code,2�qdt1 ryy Iyscn Li Is m full fort
w z i w,o License Cmsr[Z[[,L.71ic,Number.. __ -� .%. 0
'9 w F Uete Comractor " ' '
H BUILDING PER
h¢ ¢ w a OWNIi R-EUI LI)IiR DECLA RA INFORMATION
don" MISC.- REFER TO ORD
w 3 0 y I hereby affirm that I s. exempt from,Bu Contractor's License VALUATION $/FT.
F LL o a Law for the following reason(Sec.7031.5.Nosiness and I'rol'esxions PERMIT ISSUANCE 6.00
Code:Any city or county which requires permit to construct,alter, r
¢ 2 G p improve,demolish,or repair any structure,prior a its issuance,also ELEC.CONTR. - LIC.NO. ELEC.
u w m, requires the applicant Lor such permit to file a signed statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Cun rachn's License
r z i
Law(Chapter 9(commencingwith Section 7000)of Divisiou3 ofthe Al e�
4 Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
T o
¢ I- the naris for the ullcgcA exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
La by any applicant fora permitsubjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollar,(8500).):
❑ 1,as owner of the property,or my employees with wages us BACK FLOW PROTECT. DEVICE 2.00 ,ocC.GROUP RES.UNITS
their sole compensation,will do ti work,and the structure is not
Intended or.ofluLl for sale (See 7044, Buoi. nd NufaWou, DRAINS-FLOOR,ROOF,AREA,COND. 4.00 *Y„ •'^t..,,�
Code -The Contractors Liceloe L Iw does'not apply to un owner of -
property who builds or improves thereon,and who does such work FIXTURES .T
-.PER' RAP• 1 - :4.00 SO:FT.FLDOR AREA TOTALACREAGE
himself or through h s e sin employees provided that such improve.
metals are not intended or offered for sale.IL however,the budding GAS-EA.SYSTEM-11NC.4 OUTLETS 4.00
or ropy vcment Is sold within Coe year of completion, the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will(lave the burden of proving.that he did not build or im-
prove for purpose of sale.), ir RES IND PB Ounia
❑ I,as Own f the property, m exclusively contracting wit" ° Fn • . ❑ ❑ 10 ❑ 11,
�,
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESS ae RCEL 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 con(raclons)licensed pumount to
the Contractor's License Law.- SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec: ";B.&P.C.forthis WATER HEATER W/VENT 4.00' F
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPENSA'TION DECLARATION WATER TREATING EQUIP. 4.00 .•
I hereby affirm that 1 have a certificate of aimsent to self-insure. ZONING or a cetldrLme of Workers'Compen inion 1.....ra..... o}r�a�Lerlfied ENG.SITE NO.
copy thereof lSee.3600,LAC.): -
PnIIcyN E(Y j�Mnpany
+Q"' Ce e u I mre4Yl rs led, �.."r--,. .-.:+,�� - "R; - -'tit. ..FIR PRINK ENERGY Tia--
z J lg/CertifKd copy Is filed with the city mspectmn drviswn MISC.- REFER TO ORD.
0 n t Y ❑ N❑ Y ❑ No
Crw CER - I A 'EOFE IiMPTIONPROF WORKERS' PERMIT ISSUANCE 5.00 - "' -FLOOD ZONE A.L.U.O.-
LUJ COMPENSWION INSURANCE PLG.CONTE. LIC.NO, PLG. N V • N
d 0 (This section need not be completed if the permit is for one TOTAL ❑ ❑ ❑ ❑
Z lin odeed dollars IS 100)or less.)
U 0 1 certify that in the performance of the work for which this per QTY. MECHANICAL PERMIT - FEE FEE SUMMARY
Il I- mit is issued,1 shall nor employ any person in any manner see as to y`
U become subject to the Workers'Compensation Laws of Calilornia.
U a Dale-Applicant ALTER OR ADD TO MECH. 4.00 BUILDING '
} to NOTICE:'1'O APPLICANT: If,after making this Certificate of fix-
♦- Z emption,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 10MC.F.M.) 3.00
CONSTRUCT ION LENDING AGENCY _ - AIR HANDLING UNIT(OVER 10,000C.EM.15.00 SEISMIC FEE
I hereby xffhnn that (here is a ainstructim,lending agency far EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work fur which this permit is issued(Sec. MICROFILM
3097,CR.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name - HEATING UNIT(OVER 100,000B.T.U.)7.50 ELECTRIC '
Le..der'.,Address
I certify that 1 have read tlhis applieatimh anA Mate Ihm the anove VENTILATION FAN (SINGLE) 3.00
information 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 100,0008.T.U.) 4.00
ii
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100p0G BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harniless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,jodgmmts, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
4 nhny in an wiy aucrc against said City in consuluuncu o the
Y gmnlin• s iiia .MECH,CONT. LIC.NO. IMECH.
TOTAL 3 TOTAL
5 an . to d�0
INSPECTOR COPY