6860 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATION PERMIT NUMBER
BUILDING cS7oveuJs Ck K (3LLUlJ APPLICATION & PERMIT
A...Ess
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL Q v6 0
OWNER'S PLAN CHECK VALIDATION
/fos[" I 914 CITY. ELECTRIC PERMIT FEE
• V'[ ��/S ' PHONE
coAAN��rnncTOlrs CLC/UT "� OUTLETS-SWITCHES-RECEP 5.00/1.00
I'vLl u,b//1/ VJ LIc.No. n LIGHTING FIXTURES 5.00/1.00
caNTRACTOR's/e�& 7 MV;/ X9 ) Qv PPLI ANCES-RESIDENTIAL 4.00
AOD Ess (/
PHONE s PANELS 5.00 DATE OF.APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARCHOR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ESS
ZIP TEMP.METER OR POLE INS. 15.00
APPu E. /p � S.TC� 'ed MOTORS SEE FEE SCH. (Uy'
AOORE55 ee��
a g ,¢ pJ - (j/ SERVICE CHANGE. 10.00
o 0 o LICE NSED CA IRACTORS DECLARATION /�/�,f•
a o I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
w
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
R n z P,ol'cssiuns Code,.nd Y[teems u in full force' 1r(e((k'.pp[[''
a O w- License Gla - Lit.Nmnber, � � El El
Q w Datc Contractor
a r f BUILDING PERMIT
SE S, w a OWNER-BUILDER DF:CLARA'I'IOK INFORMATION
w 3 LL r I hereby affirm that I am exempt from the Contractor's License
MISC.- REFER TO ORD
Fuoj Law for the following reason. 7031.5.Busiucssand Professions -PERMIT 6.00 VALUATION $/FT.
a Code:Any city or county which Rquiresu permit toconstruct.alter,
IS a ¢ 0O - improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.rv0. ELEG
LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
wm he is licensed pursuant to the provisions of the Contractor's License
H z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe L CT
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
IS o the basis for the alleged exemption.Any violation of Section 7031.5 - STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civilp'enalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my empluyeept,ilh wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.urvlTS
their sole cmnpensation,will do the work,and the'structure is not
intended Or offered for sale (Sec 7044. Buss,&and Prufessiuw DRAIN LODR, ORF,AREA,COND. 4.00 ��
Code:The Contractor's License Law does rud'apply to ml owner of
property who builds or improves thereun4nd who does such work FIXTUR -PER TRAP 4.00 50.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own enlployees.,providcd that such improve-
mepts are not intended or offered fyy(sale.If,however.the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00 41
or improvement is sold within muf year of completion,the owner-
builder will have the burden(?]"Proving that hu did not build Or iin- GAS-EA.SYSTEM-OVER 4 (EAJ 1.00 BUILDING USE
prove for purpose.1 xale.),/ INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB Om.,
❑ I,as Owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors toemom,ucl the project(Sc, 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
end professions Code"I'hc Contractor's License Lnw docs not apply
to an owner of property who builds.or improves thereon.and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
commets for such projects with a contractor(s)licensed pursuant to -
the CmUnc6r'sLiccnscLaw. SEWER-SANITARY-STORM EA.200ft/8.00 ,Qj TRACT NO. PARCEL No.
❑ 1 ou exempt under Sec ,B.&P.C.for Ili's WATER HEATER W/VENT 4.00, 4
reamll
Owmcr Date WATER SYSTEM 4.00 ACC.DATE Aec.FILE No.
WORK ISRS'COMNiNSkI ION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure. - ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy[hercy1 fs•c 3800,Lah.C.).
Policy No SC I Cnlnpany Aln,f7 WeSreXA)
Q ❑ Certified Cop'ie hereby'fumfshed- FIRE SPRINK ENERGY T 24
CcrUficd y s led with thc rly ospecflon division. MISC.- REFER TO ORD.
Z z LL�� JA C-
O Ap(fl11it ` Y ❑ N❑ Y ❑ N❑
� N CliRlll%G\'I'li OPli%I:IPTION FROM WORKERS,
PERMIT ISSUANCE 6.00 .0U FLOOD ZONE A.L.u.c.
LU > COMPENSA'1'1 ON INSURANCIi n .CONTH. LIC.rv0. 'l PLG. S'
CL O (this section need\ml be completed if Heil is for one 17r�P y TOTAL �Q,Q� Y❑ N❑ Y❑ N❑
Z hundred dollurs(SI00)zIc.,)
V O I certily that in the pertQrmuace of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not emp1qy�y person in any manner so as to
U become subject to the Workeryl-timpensxtion Laws of California.
O w Dale Al+plic nl \ ALTER OR ADD TO MECH. 4.00 BUILDING
} m NO1'ICP. 'fn AI'1111(f If,,xflc�ing this Ccrlificale of Ex-
F2 eruption,you rhos recorue subject to to orkers Compensation APPLIANCE 4.00 PLAN CHECK
provisions of Labor Code, you must fo hwith comply with FEE
V such pr1'visju s or this permit shall be deemed revoked./ AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING ADENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I herchy affirm that there is a con9.trd�<t n lending agency for EXHAUST HOOD(WITH DUCT) . 2.00
the periormance`n1'the work lin it ch this pernllt is issued(Scc. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ.C.).
Bender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify fit ave rea is application and stale that One above VENTILATION FAN (SINGLE) 3.00
• rotor natio s correct. I agn to comply with all City and county PLUMBING
ordinay s and stale laws relu 'ng m building construction, and BDILER-COMP(3H.P.or 100,000B.T.U.) 4.00 ✓
hcretfy aumorizc representatives 1' this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly for inspe on 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 iI any w-y accrue against said City,ln consequence of the PERMIT ISSUANCE 3.00
910.F oft permit. MECR.CONT. LIC.NO. MECH.
�� TOTAL TOTAL
Signature of Ap ant/Contractor 11 Date
INSPECTOR COPY