5670 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL PONT PEN ONLY
PERMIT NUMBER
u'I. ING. DING PROJECT IDENTIFICATION APPLICATION & PERMIT
em LOIN.. , ^ o
' AGGRESS 1, {J�
�O BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OVINE PLAN CHECK VALIDATION
"A"= CITY. - ELECTRIC PERMIT FEE
• N9/V.✓ // PHONE `
cANTRRcrops
AME OUTLETS-SWITCHES-RECEP 5.00/1.00
N /
/ LC.NO. b3 LIGHTING FIXTURES 5.00/1.00
r, ofl's
ADDRESS PPLIANCES-RESIDENTIAL 4.00
PHONE J��/ PANELS " 5.00 DATE OF APPLICATION
ARCHITECTSIGNS 600 PLAN CHECK FEE P,C.NO.
OR .
ENGINEER
c.No. SIGNS TRANS. 3.00
ADD ESS EENG. u - SPECIAL CIRCUIT, 5.00 PERMIT VALIDATIO
zm TEMP.METER OR POLE INS. 15.00
AEMOTORS SEE FEE SCH.
ADDRESS
AS
SERVICE CHANGE 10.00
0 0 o LICENSED CONI'RACI'ORS DECLARATION
a v I hereby affirm that 1 ant licensed under provisions of Chapter 9 ISSUANCE DATE
"' fconunencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MI
r'F' N i Professions Code,and y license is in full force'nd •fife. ❑ ❑ Cl
z o m - Licem•Cla: Lie.Number t
Q zl-w Datc 6�7Z f Contractor
Y f .Ji BUILDING PERMIT
o: w Q, OWNER-BUILDER DECLA PION INFORMATION
..WoaU MISC.- REFER TO ORD
3 LL N 1 hereby alfinn that 1 am exempt from the Contractor i License VALUATION SIFT.
j Law Err the following reason.(See.7031.5,Businessand l'rufessiuns PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,alter,
RQ improve,demolish;or repair any structure,prior to its issuance,also ELEC CONTH. LIC.NO, ELEC.
0 LL cc a rc,Il a applicant for such permit to file a signed statement Iliat TOTAL PERMIT TO
X m he is licensed pursuant to tire provisions of the Contractor's License
Hzi Law(Chapter 9(commencing with Section 7000)oft)ivision 3 ofthe
a .Business and Professions Code)or that he i5 exempt therefrom and QTY. PLUMBING PERMIT FEE
r o/ the basis for the alleged exemption.Any violation of Section 7031.5 - STORIES TYPE CONSTR.
vazW by any applicant lorupermit subjects the applicant VIA civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of nut more than five hundred dollms(5500).):
❑ I,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 sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,GOND. 4.00
Code:'fire 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 or through his own employees.provided that such im Prov.
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 4.00
or improvement 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 an- RES IND CON Pe Omar
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑ ❑
❑ 1,as owner of ibe property,um exclusively contracting with
licensed contractors to construct the project five 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to en owner of property who builds or improves thcmom and It. LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the ContraZOW,License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT No. PARCEL No.
❑ lam exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owocr Late WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORK ISRS'COMPI:NSA1ION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm IT at 1 have a certificate of consent to self-insure. ZONING
or a certificate of WOrkcri CHm PcrSatl0n Insurance,or a certifieA ENG.SITE NO.
copy them(Sec.3800,Lab.C.I
Policy Nii''- Company '
Q ❑ Ccrllf icd cul'y is lxreby furnished. G FIRE SPRINK ENERG7T-24
Z-ZbC Certified copy filed with Jm-c' inspection division. MIS4- REFER TO ORD.
O ' ,,Icant - y N❑ r ❑ IND
IrN CER'rllric, SOF EXEMPFIONFROxt WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.Lu.C.
LU > COMPHNSA'I ION INSURANCE PLG.CONTR. LIC.NO. PLG. N
CL O (This section need not be completed if the permit is for onV e TOTAL ❑ ❑ Y ❑ N❑
=) Z hundred dollars($100)ur less.)
U O I certify that in the performance of the work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL F ntit is issued, I shall not employ any person in any manner so as to
U become subject to the Workeri Compensation Laws of California.
Ed Uute Applicant G ALTER OR ADD TO MECH. .00 BUILDING
.} W NOTICE TO APPLICANT: If,after making this Cert ilicatc of Ex-
F Z empti0n,You Should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
prm'isio(;s of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be demeeddevokcd AIR HANDLING UNIT(TO 10=C.F.M.) 3-00
C CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is A Construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this'Permit is issued(Sec. MICROFILM
3097,CiC.). HEATING UNIT(TO 100,000 B.T.U.) 4.00 v. ,
Lender i Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Andress ELECTRIC
I certify that I have read this application and state Ihal the above VENTILATION FAN (SINGLE) 3.00
infnrntation is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives yf this city (o enter upon the BOILER-COMP (Over 100,000BTU)SEEFEESCH. MECHANICAL Q
ebov.nmmioned property for ingpectiun pu
IT,oscs.
(We) agree to save, indemnify and keep harmless the City of MISC. ''1 REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE t �� CONST.TAX
may in any way aeeme against Said City in consequence of the /O (J
granting of this ynnil.' MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signotar, AIpiant/CornmetorUare
P INSPECTOR COPY