6783 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
ADDRESS APPLICATION & PERMIT _ ����
ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNERS PLAN CHECK VALIDATION
"AME OTY. ELECTRIC PERMIT FEE '
PHONE
N°meCONTRACTORs UTLETS-SWITCHES-RECEP 5.00/1,00
LIC.NO, LIGHTING FIXTURES 5.00/1.00
cO ACTORS ' APPLIANCES-RESIDENTIAL 4.00 /
ADDRESS
&.E -jrPANELS 5.00 DATE OF APPLICATION
I C rt SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
' Llc.No. SIGNS TRANS. 3.00 7
ARCH,OR ENG. PERMIT VALIDATION
ADDRESS SPECIALCIRCUIT 5.00
I ZIP rrEMP.METER OR POLE INS. 15.00
APPLICANT'SIL�w/,nfJ' MOTORS SEE FEE SCH. S
ADDRESS l/W/LCV
SERVICE CHANGE 10.00
Do ..
¢ z /v
F o 0 LICISNSI:D CO "1'RACI ORS Df:CLARATION
<u u � I hereby afferm that I am licensed muter provisions of Chapter 9 ISSUANCE DATE
h Q y Icomnuncing with Section 7000)of Division 3 of the Business and - BLDG. ELECT. PLG. MECH.
F N z I'rofessisns C license is in full lirrc• n i
z O m License Class ' Lie Number_ - El 1:1 •0 ❑
9 H w IJatc_q.��l-1- _D[�CanlructnrIr
¢ m OG ot-Oa.� BUILDING PERMIT
OWNER-BUILDER DECLARATION INFORMATION
w0` I hereby affirm that 1 am exempt four the C'ontractor's Liccme MISC.- REFER TO ORD
30 Y' p VALUATION SIFT.
Fu Oj Law form citylowingrey which 703
a perminess t tocndtrut,altes PERMIT ISSUANCE 6.00
Code:Any city or county which requirese permit to construct,alter,
2 sc Q Improve,demolish,or repair any Structure,prior(o its iSauane'C,also ELEC.CONTR. LIC.NO. ELEC.
F u requires the applicant for such permit t0 file signed statement that TOTAL PERMIT TO
w he is licensed pursuant In the Provisions of the Contractors License C+
H z i
Law(Chapter 9(coemencing with Suction 7000)of Division 3 of lire MtC�
a Business and Professions Code)or that he is exempt it..etrorQTPLUMBING and QPLUMBING PERMIT FEE
¢ 0 the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTH,
u5-: � by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(5500).):
❑ 1,as owner of the property,or my 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 sal (Sec 7044, Business and 1'rol'cssime, DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Com nmtor s Lie
use Law does not apply to an owner oI '
property who buil s o m users threon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT FLOOR AREA TOTAL ACREAGE
himself or❑vsugh is employees Provide)that such improve .
menu are Roti tem• r or
for sale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 4,00
or improvemTL Si d within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
Id,"will h v,. uN.l.en of proving that he did not build or im- RES IND CON PB Omer
Is for o. of saleINDUSTRIAL WASTE INTER. 20.00
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed can(sectors to construct the project(Sec.71344,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
ro an owner of property who builds or improves tlmremr,and who LAWN SPR INKLERS-OV ER 5(EA.) 1.00
contracts for such projects with a cmDractous)licensed pursuant In
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I um exempt muter Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner - Date WATER SYSTEM 4.00 ACC.DATE ACC.FILENO
-
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm this 1 Imve a certificate ofeansent nr self-inoue' ZONING or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thcrentIScc.3800,Lab.C.) `z
Policy No.
Q ❑ Cert itied copy 4 ere u'"!I the
FIRE SPRINK ENERGY T-24
i.��ryr�Certllie I ¢ filed with the city inspection division. MISC.- REFER TO ORD.
z 0 Appr¢a Ter Y❑ N❑ V ❑ N❑
� = CERTIFICA'1'1:OF EXF.MPIION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
Lu > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
❑ (this Section need or be completed if the. cm.it is for one TOTAL Y❑ N❑ I Y❑ IN❑
Z bund and dollars is 100)of less.) '
U O 1 certify that in the performance of Orn work for which this per- QTY. MEC NICAL PERMIT FEE FEE SUMMARY
11 I- mit is issued,I shall not employ any person in any mann,,so as to
U Date subject to the Wlicant Compemation Laws of Culifomiu.
0 a Date ApplieanrALTER OR ADD TOMECH. 4.00 BUILDING
>- Do NOTICE TO APPLICANT: If,after making this Certificate of E.-
H Z 'option,you should become su "ect m the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the labor Code, ou must forthwith comply with FEE
CJ such provisions or this permit Sir I be deemed revoked. AIR HANDLING UNIT(TO 1Op00C.F.M.) 3.00
CONS'I'k J , iO LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 5.00 SEISMIC FEE
I hereby aVJVkf"oLr'
is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performark fur which this permit is issued IScc. HEATING UNIT(TO 100,000 B.T.U.) 4.00MICROFILM
3097,r%Na.lLender's AdmHEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lrnder's AJJ1 certify thrs application and state that Die above VENTILATION FAN (SINGLE) 3.00inform tionree to comply with all city and county PLUMBING
rdinan�cos qrelating,to building construction, and BOILER-CONP(3 H.P.or100,000B.T.U.) 4.00
hereby er orite representatives of this city to enter upon the BOILER-COMP(Over IW,000BTU)SEEFEESCH. MECHANICAL /-3�
above-mentioned property for inspection purtai
(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 ry way accrue a cent Said City in consequence of the PERMIT ISSUANCE 3.00
an Is i Per Set. - MECH.CONT. LIC.NO. MECH.
TOTAL/ - TOTAL
Sign tar pp 'ant/ onImctor U.Ir,
INSPECTOR COPY