7058r -
APPLICANT TO FILL IN INFORMATION WITHIN RECLINES - USE BALL POINT PEN ONLY
s-"
BUILDING PROJECT lDENTIFICATION PERMIT NUMBER euILOING APPLICATION & PERMIT
A
ADDRESS
DS S BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 0uu
OWNER'S PLAN CHECK VALIDATION
"AME QTY. ELECTRIC PERMIT FEE z i
{, ONE - I,
croRs
NAME UTLETS-SWITCHES-RECEP 5.00/1-00
NOME
r T LIC.No. 1 LIGHTING FIXTURES 5.00/1.00
CONTE TA
ns ADD -A- u S(7')5 PPLIANCES-RESIDENTIAL 4.00
CON
A PHONEC171-0447rr PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 ,PLAN CHECK FEE P.C.N0,
OR
ENGINEER
' uc.NO SIGNS TRANS. 3.00
ADDRESS ENG - SPECIAL CIRCUIT '5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANT ESSss MOTORS SEE FEE SCH.
(Z
SERVICE CHANGE 10.00 v
o0z
. r D o LICENSED CONTRACTORS DECLARATION
G o I, 1 hereby aflinn that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and LD ELECT. PLG. MECH.
r <z Professions Code and my license is in full for,, d e(fcd-
zow- License ClassCA55CtJgic.NNmber <Cd,
!(-)�i U.�i E
o zDateJContractor e' .wL
j BUILDING PERMIT
g, w a OWNER-BUILDER DECLARATION INFORMATION
nos ° MISC.- REFER TO ORD
K 3 u r I hereby attire that I am exempt from the Contractor s License VALUATION
LL o sr Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
� - Code'.Any city or county which requires a permit toamstruct,alter, 6
re 4 p improve,demolish,or rep r any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. FL EC,
o u rees quirthf
e applicant or such permit to file a signed statement that TOTAL PE MITT
tem he is licensed pursuant to the provisions of tiro Contractor's License
au z i Law(Chapter 9(commencing with Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
`X F o the basis for the alleged exemption.Any violation of Seclion 7031.5 STORIES TYPE CONSTR;
La
n ate _ by any applicant for a permit subjects the applicant In a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
a of not more than five hundred dollars(8500).):
}- ❑ 1,as owner of the property,or lily employce 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,AREA,COND. 4.00
Code'file Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRnAP ` ` 4.00 So.PT FLOOR AREA TOTAL ACREAGE
himself or through his own employe,provided that such....prove-
mems are not intended or offered for Sala.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
or intprovemonl is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 (EA) 1.00 BUILDING USE
INDUSTRIAL WASTE INTER. 20.00
builder will have the burden of proving that he did not build or in,- - . - ,
Es IND cG PB - Deer
prove for purpose of sale.)
❑❑ 1,as owner of the properly,anl exclusively contracting with El El El
licensed contractors pi construct the project(See.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
end Po,lroiuns Code:'The Contractor's License Law docs not apply
to in owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to
the Contractors License Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
CI I am exempt under Sec. ,B.&p.C.for this WATER HEATER W/VENT 4_00
rcuson
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.-
WORKERS'COMPEN'SA'I ION DECLARATION WATER TREATING EQUIP. 4.00
hereby affirm That 1 lielve acertificah,of consent to s If Insure, ZONING ENG,SITE NO.
ora elpri,litcof Wok s Compens do I I...m nc or a certified
1,(Y
city th ar-(S 3800 Lah.C)j I ohcy N AFA14.CmRpmy O'-)cYC/S4 Q;61reA
1' �0 ❑1�p/Crtilicd lylsI by ruhd FIRE SPRINK ENERGY T-24
/// L z I(-`.t:t)ed l.n s IIIed with}he City m,clm doi9 On.
O Applicant (L �rcl MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
~ vi R �C- PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.uc.
{tom - CliR 1'lll A'I'li Cl,l?XFMPTION PROM WORKERS'
t,L �_ COMPENSATION I NSURANCE PLG,CONTE. LIC,NO. PLG.
n CL O (This section Iced not be complcled if the permit is for of TOTAL YE] N❑ Y❑ N❑
s 'F' Z hundred dollars 1$1001 or less) e
0.0 1 certify that in the performance of the work for which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H
Lmit is issued,1 shall not employ any person in any manner so as to -
U beconm subject to the Workers Compensation Laws of California.
Lu
Date Avplicanl ALTER OR ADD TO MECH. 4.00 BUILDING ,s
} N NOTICl: '1'O APPLICANT': 1f,after making this Certificate of Ex-
Z cnlplion,you,should become subject to the Workers'Compensation APPLIANCE 4-00 PLAN CHECK 1
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1Op00 C.F.M.) 3.00 FEE 1<
CONSTRUCTION LENDING AGENCY, AIR HANDLING UNIT(OVER I0,000C.EM.) 5.00 SEISMICFEE
I hereby affirm that there is a construction landing 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 d
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I ifythat Ihave read this application and site that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I age to coriply with all cit,and county PLUMBING 1 I
d a - and rt laws relating m b 'Idle, oust cli n, and BOILER-COMP(3 H.P.or 100,000 B.T-U.) 4.00 V
hereby authorlr.e ropoisenmlives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree In 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 in any way aeeme against said ity in consequence of the
granting oftl spermit MECH.CONT. LIC-NO- MEC".
TOTAL TOTAL -_-
Signa cot`APPIien4C7;huetor ate ��•
INSPECTOR COPY