6626 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT lDENTIFICATION PERMIT NUMBER BUILDING APPLICATION & PERMIT ADORE
ss
211-1 6626
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNERS PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
E CKRU PHONE
i NAM[RAcaoRS UTL ETS-SWITCHES-RECEP 5.00/1.00
No. LIGHTING FIXTURES 5.00/1.00
CONTRACTORSADDRESS PO+eOx �O� {15` PPLIANCES-RESIDENTIAL 4.00
1
FRE-MCKT, Ch 9V5 PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT "/ SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALI DATION
ADDRESS SPECIALCIRCUIT 5.00
ZIP TEMP.METER OR POLE INS. 15.00
APPLIEAN�TS. MOTORS SEE FEE SCH. /
SERVICE CHANGE 10.00 i( I
o o LICBNSIiU CONTRACTORS DECLARATION
a U U I hereby affirm that I am licensed under provisions of Chapter 9 ISBUANCE GATE
m Q T (commencing with Section 7000)of Division 3 of the Businessand BL ELECT. PLG. MECH.
H H z Professions Cody,andjny license is in full force and f el ❑ ❑ ❑
,e O m - License Class 6-0lip-Lie.Number
9 va r w Date. -I3=�: Contractor -
¢ m s " BUILDING PERMIT
¢ ¢ w ¢ OWNIi R-BUILDER DECLARATIO INFORMATION
aoA. � - MISC.- REFER TO ORD
w 3 u I hereby ufEnn that 1 um exempt from the Contractor's License VALUATION
F LL O¢ Law for the following mason.(Sec.7031.5,Businaes and Professions PERMIT ISSUANCE 6.00 S/FT.
Code:Any city or county which requires a permit to construct,alter, y
¢
via
. , < O improve,demolish,or repair any structure,prior m its issuance.also ELEC.CONTR. LIC.NO. ELEC. /.-/
- ¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
e_ w m y he is licensed pursuant to the provisions of the Contractor's License
rZs
Law(Chapter 9(commencing with Section 7000)ofDivision 3 of the
¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE kily
f i O
¢ Hae
the
nyapor the alleged exemption,subjects
Any violation ofusction 703L5 STORIESTYPE CONSTR.
;m by of room
applicant fora permit subjects theapplicant tuacivil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not mom than I'iv,hundred tlollars($500t):
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 2.00 occ.GROUP RES.UNITS
their sole compe,n ation,will do the work,and the structure Is not
intended or offered for sale (Sec 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds ur improves thereon,and who does such work F IXTUR ES-PER TRAP - 4.00 SOL FT FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
fonts are not intended or offered for sale,ll',however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4,00
or Improvemetlt is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BW L IN USE
builtler will have Ih,burden of proving that he did not build or in' RE& IND PB Omar
pro fors rens,of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑
❑ L c owner of the property,he exclusively contracting with
licensed contractors In construct the project La 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS gRCEL N0,
and n owner of Code: Iropert he Contractor's o License Law does not apply ho
Io contracts
owner o!property who builds tr improves
ensed pursuant
who LAWN SPRINKLERS-OVER 5(EA.) 1.00 .
tineCot for such projects with a contractoR sl licensed pursuam m
the Contractor's License La, SEWER-SANITARY-STORM EA.200ft/8.00 Tflgcr NO. PARCEL N0.
❑ lam,xemptonder See. ,B.&PCforthis WATER HEATER W/VENT 4.00
reason
Owner [)ate WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSA'IION DECLARA'T'ION WATER TREATING EQUIP. 4.00
I hereby affirm (hut I have a certificate of consent to self-insure. ZONING
or a certificate of Workers'Compensution Insurance,or a certified
ENG.SITE N0.
copy mereofYSec.38oQ1.dV.). MAtiLyVANO
rnhcy NGT�yA2Q 'p3br) 3'F .A`a�1A1a Y �
Q ❑ Ceoille Copyu crt urmsreJ. (,Q FIRE'SPRINK ENERGY T2s
Z 2 §L Cer iiyd/,.py s f d w' I ra y inspection division. MISC.- REFER TO ORD.
O APPlicq//12 - Y ❑ N❑ Y ❑ N❑
CHR'I''llQ'^IL'',-i-'I'eor EXEMVnON FROM WORKERS' PERMIT ISSUANCE 6.00 fL000 ZONE A.Lu.c.
W 7 COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. V❑ N❑ Y [:] N❑
CL Z ('f his section need not be completed it' the permit is for one TOTAL
hundred dollars IS 100)or Tess-)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE - FEE SUMMARY
LL,H mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
a Date ApplicantALTER OR ADD TO MECH. 4.00 BUILDING
} En NOTICE TO APPLICANT': IL after making This Certificate of Ex-
F Z unlption,you should becon c subject to the Workers Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, You must forthwith comply with FEE 'O(Q, /
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UN IT(OVER 100100 C.F.M.) 5.00 SEISMIC FEE l ( I
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,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify (list I have reed I his application and state that the above VENTILATION FAN (SINGLE) 3.00
inlimnation is correct, I agree to comply with all city and county PLUMBING
ordinances and slut, laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby uuthmire representatives of this city to enter upon the BOILER-COMP (Over 100,00 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purpose,
pv,) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino,against liabilities,judgments,costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
/ may m y way44,U
, aff, east er City in consequence of thugr' i (this p / MECH.CONT. LIC.NO. MECH. 'fQ/ / OT"` TOTAL ZI�'ontrucmr IJule
INSPECTOR COPY