3611 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT 3611
AD ESs
�j� �� BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
jsl S PLAN CHECK VALIDATION
/ OTY. ELECTRIC PERMIT FEE
• '_� PHONE
WNAr AcroRs UTLETS-SWITCHES-RECEP 5.00/1.00
� D sec.No � LIGHTING FIXTURES 5.00/1.00
T ALTO APPLIANCES-RESIDENTIAL 4.00
� PANELS 5.00 DATE OF APPLICATION
HITECT SIGNS 6.DD PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC,No. SIGNS TRANS. 3.00
ARC Ess ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP rFEMP. METER OR POLE INS. 15-00
CANr Es r MOTORS SEE FEE SCH.
III ,�, SERVICE CHANGE 10.00 !
woo LICENSED CONTRACTORS DECLARATION
<
is I hereby affirm that I am licensed under Provisions of Chapter 9 - ISSUANCE DATE
m<H Iconunencing with Section 7000)of Division 3 of t urine BLDG. ELECT. PLG. MECH.
F w z Professions Co d my license is in full force
G
o m - hicunsc Class �n Lie Nmnbcr El ❑
H Uale Contractor
a r E
ir Oµ.\ LDER DECLARATION INFORMATIONUIre- BUILDING PERMIT
A oa " MISC.- REFER TO ORD
w 3 LL H I hereby uffum firm I din exempt frau the Commctor's License VALUATION 5/FT.
H .Loa rLuw for the following Teason.(See 7031.5,Busincssund Professions PERMIT ISSUANCE 6.00
Code Any city or cotmty which requires u permit W construct,11111.
l-Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. TE LEC.
ricor R m R req Wres the applicant for melt permit to file a signed statement flat TOTAL
he is licensed pursuant to the provisions of the Contractor's License I PERMIT TO
H z i
Law(Chapter 1)(commencing with Section 7000)of Division 3 of the
aItusiness and Profession"Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
"¢ FO the basis for file alleged exemption.Any violation ofSCCODn 7031.5 STORIES TYPE CONSTR.
c. by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of nor more than five hundred dollars($500).):
❑ I,as owner of fire property, Ing employee with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the stnmture Is not
'vended or offered far sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law docs 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 TOTALACREAGE
• hinnsulf or Ihnmg),his own employee.,provided that such impmvo-
menu are not intended of offered far Sade.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
or improvement is sold within one year of completion.the owner- GAS EASYSTEM-OVER 4(EA.) 1-00 BUILDING USE
builder will have the burden of proving that he did net build or im - . .
-of RES IND CON PB Omer
prove for purpose,,!..lest INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑ ❑
❑ 1,as owner tire :e property, mlusvcly contracting with
licensed emraaors to cunstnet the project IS11. 7044,BusinessLAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:"f he Contractors 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 contractim !licensed pursuant to
the Contractor's Llceasc L.A. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ ISI,,cxcmpt un der See. .B.&P.C.Ibr this WATER HEATER W/VENT 4.00
reason
Late Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSA'MON DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a cern!;, o consent to xcl f-in ore.
or 1 cerld Cap,of Worker;Compensation 1 umnce,or a cer ficd ZONING ENG.SITE N0.
Copy the 00,Lan C.).
pony N camnany
O lm il'icd copy is hercby:Pornisl 1. FIRE SPEINK ENERGY T-14
Z Z `y'', C. ificd c is irk -w i tl city inspection division.
O AlrplicsntMISC.- - REFER TO ORD. Y ❑ N❑ Y ❑ N❑
X W CE "IC 1,701.IiSI St 1110\ 'kW KERS• PERMIT ISSUANCE 6.00 FLOODZONE A.UU.C,
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. si _
CL 0CL 2 1'1"his sect itis need not be completed if the .....nit is lit.ant TOTAL YQ ,,N❑ v ❑ N❑
hundred d.11...($100)or less.!
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
L.L F mit is issued,I shall not employ any person in any mature;za as to
Q w become subject to the Workers'Com Pensation Laws of California.
d Dal° APpheamt ALTER OR ADD TO MECH. 4.00 BUILDING
} y NOTICE '1'0 APPLICANT: If,alter making this Certificate W lix-
Z
violation,you should become subject to fire Worker Comprnsurion APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such Provisions,,,this permit shall be dceaned revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm Ilia, there is a const coon lending agency for EXHAUST HOOD WITH DUCT) 2.00
the performunee of,he work for whi his pe mit is issued ISec. MICROFILM
3097,Civ.C.1 HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender'.Name
Lender's AJJrc �, HEATI NG UN IT(OVER 100,000 B.T.U.17.50 ELECTRIC
s
lccrtify ser Is pp nation an state har rinc.bare _zy VENTILATION FAN (SINGLE) 3.00
into
nn are"
is correct laag"e to comply with all city and county UMBING
ordinances mW state laws relating to building cotranci ion. mo BOILER-COMP(3H.P.or100,000B.T.U.) 4.0
hemby umhorite repmscnmtives of this city In enter upon the BOILER-COMP (Over 100,000BTU)SEE FEESOH. MECHANICAL f/p
above-mentioned property for meptt4ilm proposes,
(We) agree to save. Friction inn d keep harmless the City of MISC.- REFER TO ORD.
Cupertino against Iiabilitics, dip nu, cost, and expenses which CONST.TAX
miry ny way �iAm I ,Inst mA City nsniuencc 11 the
PERMIT ISSUANCE 3.00
gr;mPi� (this •m'( CH.CONT. LIC.NO. MECH.
LI)
OTALTOTAL
fur of pplicunt/CamoR o
INSPECTOR COPY