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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
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" `BUI LDI NG PROJECT IDENTIFICATION
APPLICATION & PERMIT
-
BUILDING - ELECTRICAL- PLUMBING MECHANICAL
PERMIT NUMBER
5855
6. LUNG �/1 { 1 IC ^.p y
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OWNER'S
p
PLAN CHECK VALIDATION
NAME
CITY. ELECTRIC PERMIT FEE
PHONE
CONTRACTORSC
NAME u /^�, / /�
NH �l: /'/ LIC. No. 404'z
UTLETS -SWITCHES-RECEP 5.00/1.00
DATE OF APPLICATION
LIGHTING FIXTURES 5.00/1.00
-CONTRACTORS
AOD7REsss
-5 / Nr 7� r PRONE (r +e+
PPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
ARCHITECT
OR
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
TRANS. 3.00 y
''
ENGINEER
I.W. rvo.SIGNS
.
ADDREgs ENG'-
SPECIALCIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 15.00
- x,s
/y
gPPucANrs
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, d li ensa is in full fmc an ec .
-in
!' Lica Number ] �%�
ISSUANCE DATE
BLDG.
s
ELECT.
PLG.
❑
Uutc�lax
T CDnvuctm
-
BUILDING PERMI
OWNER-BUILDF-R DECLARATION
I hereby, ffirm that I am exempt from the Cuntmctoh Liunse
Professions
Law: Any city
owingreywhich requires a permit to COnsuance, also
Coda: Any city or coup pair any structure,
u tune p riot it)
improve, demolish, or repair any permit to ti prior to its issuance, also
requires the applicant for such permit to file a signed Staten Li that
License
pursuant to tire withSectiof the Cool Division
heir (Chapter the
Law (Chater9(commenCode) of Section is 00) exempt theefo and
Business and Professions Code) or that he is exempt echo 70 and
the basis for the alleged exemption. Any violation ofSection 703 L5
INFORMATION
MISC.- REFER TO ORD
PERMIT ISSUANCE 6.00
VALUATION
$/FT.
ELEC. CONTR. LIC. NO.
ELEC.
TOTgL
PERMIT IO
,!. , /
eY/C!/'1/-/J ✓t�/ff/-
QTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
by any applicant for a permit subjects tho applicant toa civil pcoalty
of not more than five hundred dollars ($500).1:
ALTER -DRAIN & VENT -WATER (EA.) 4.00
❑I, as owner of the property, or my employees with wages as
their sole Compensation, will Jo the work, and the structure is not
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
intended or offered lx osale (Sec. 7044, Business and Professions
Code: It, L,Contractor's License Law does not apply to an owner of
F IXTUR ES - PER TRAP 4.00
So. FT FLOOR AREA
TOTAL ACREAGE
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
mentsare not intended or offered for sale. If, however, tie building
GAS - EA. SYSTEM - I INC. 4 OUTLETS 4.00
for improvement is sold within one year of completion, the owner-
builder will have ate burdedDf proving that he did not build or ice-
prove forpuipoae of.I,,.
1, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA) 1.00
BUILDING SE
RES IND PB Omer ,
El❑.
❑ El FR
INDUSTRIALWASTE INTER. 20.00
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
_ASSESSVS PARCEL NO.
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code:'I he Contractor's License Law does not apply
to an owner of property who builds or improves thereon. and who
contracts for such projects will, a cart ractons) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ lam uxmnpt under See ,B.&P.C. for this
reason
WATER HEATER W/VENT 4,00
Owner Date
WATER SYSTEM + 4.00
ACC. DATE
ACC. FILE NO.
WORKERS'COMPENSATiON DECLARATION
=
WATER TREATING EQUIP. /f 4.00
I hereby affirm that I have a certificate ofconsent to self -insure,
of a certificate of Workers' SompensHion Insurance. Or a certified
copy thercof(Sri. 3800, Lab.C.). �'G�1 I rJ f7�k
Policy No. ' Company 1+1 l�K.
+
ZONING
ENG. SITE NO.
FIRESPRINK
ENERGY T 24
❑ Certified copy ishereby furnished.
❑ Cerificd copy, is :='_ l - ly inspection yy}yon.
A�pli (7-L.
y N
❑ ❑
y N
❑ o
MISC..;,,,, REFER TO ORD.
C Ii R' I 11' I CA 11; OF EX I PTION PROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.u.C.
PLG.CONTR, LIC. NO.
PLG.
TOTAL
. COMITNSA'I'ION INSURANCE
(This section need not be completed if the permit is for one
Y ❑ N❑
Y ❑ N❑
CITY. MECHANICAL PERMIT FEE
FEE SUMMARY
to ndmd dollars (S 100) Or lccc )
1 certify that in the performance of the work for which this per-
mit is issued, 1 shall not employ any person in any manner so as to
BUILDING
become subject to the Workers' Compensation Laws of California.
Uwe Applicant
NOTICE 'I'O APPLICANT: If, after making this Certificate of Ex-
ALTER OR ADD TO MECH. 4.00
APPLIANCE 4.00
PLAN CHECK
emption, you should become subject to the Workers'Compensation
Pnrvislons of me Labor Code, you most forthwith comply with
such provisions or this permit shall he dtfuned revokud.
FEE
a
AIR HANDLING UNIT (TO 10=C.F.M.) 3.00
AIR HANDLING UNIT (OVER I0AOOC.F.N1)5.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 2.00
performance °I the work for which this permit is issueA (Sec.
3097 Civ.C.)
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
2 HEATING UNIT (OVER 100,000 B.T.U.)7,50 S
ELECTRIC
Lender's Name
Lender's Address
I certify that l have read this application and state that the above
VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county
ordinances and slate laws rehoo, to building construction, and
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
PLUMBING
BOILER-CON�(3 H.P. or 100,000 B.T.U.) 4.00
A BOILER -COMP (Ovar 100,000 BTU)SEE FEE SCH. Q
L
MECHANICAL
MISC. - REFER TO ORD.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said City in consequence of the
PERMIT ISSUANCE 3.00
CONST. TAX
grunfipg of this permit.,'`,MECH.
•i�iYVwc /-Z
CONT. LIC. NO.
MECH.
TOTAL
TOTAL
Signature of Applicant/Contractor Date
INSPECTOR COPY