6859 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
•
BUILDING PROJECT lDENTI FICATION PERMIT NUMBER BUILDING
APPLICATION & PERMIT -
ARE
SS
as ?ANTA u � _ _oDEBUILDING -ELECTRICAL-PLUMBING-MECHANICAL 6859
�-
OWNERS PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
ONE
CONTRACTOR UTLETS-SWITCHES-RECEP 5.0011.00
tn i
fellG M LIC....No. LIGHTING FIXTURES 5.00/1.00
ACroRs a 6y7 1;p d-;R //rPPLIANCES-RESIDENTIAL 4.00
ss_ PRONE PANELS 5.00 DATE OF APPLICATION
ECT SIGNS8,00 ' PLAN CHECK FEE P.C.NO..
OR
ENGINEER
' uc.NO. - SIGNS TRANS. 3.00 -
nooeesS ENG' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00 n /I
ADDRESS MOTORS SEE FEE SCH.
bJ I0/ SERVICE CHANGE - 10.00
woo LICI: SIiD CONTRACTORS DECLARATION
a v u I hereby affirm that I am-licensed under provisions of Chapter 9 ISSUANCE DATE
oG w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F D i Professions Code,and my Berns,is in full force and of feel. ❑ ❑ ❑
Z O w - Liccuse Clan Lic.Numbcr - _
Q 2 �w DvW Contractor ,
H BUILDING PERMIT
rc w w S .OWNER-BUILDER DECLARATION - INFORMATION o
i u a y es m t 1 hereb Minn that'1 am exefrom the Contractor' License MISC.- REFER TO OR
1' s VALUATION
HuOj lawforthe ity or corcawn.(Sec Tires a Businessand trut,a alter,
PERMIT ISSUANCE 6.00
Code:Any city air county which requires a permit to construct xlhq
¢ ce.4 0 improve.demolish,Or repair any structure,prior lu its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- O u require the applicant for such permit to file a signed statement that TOTAL PERMIT TO
X he is licensed pursuant to the provisions of the Contmetor's License ��V y�.
Hsi
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
sa. the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
aby any applicant for a permit subjects the applicant too civil penally • ALTER-DRAIN&VENT-WATER (EA-) 4.00
of not more than five hundred dollars(S500).)
❑ I,a owner of the property,or my employees with..'es as BACK FLOW PROTECT. DEVICE 2.00
their sole compenvlion,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR.ROOF,AREA,CONO. 4.00 116-e0
Axle:'rhe Contractor's Licch.law dues not apply m an owner of
...� properly who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 S0.FT.FLOOR AREA TOTALACREAGE
I
imself or Ihmugh his owncmployecs,provided that such impmve-
mens are not intended or offered for sale It however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of cmnpletinn, Ila owner- GAS-EA.SYSTEM.OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving Thal he did not build or ins . RES IND CON PB Other
prove for purpose ofsale.). - INDUSTRIAL WASTE INTER. 20.00
❑ 1,as owner of the property:am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors To construct the project(Sec. 70 .Business LAWN SPRINKLERS-1 INC 5 V.B. 5.D0 ASSESSORS PARCEL NO.
and I'mi.ions Code The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon,and who - LAWN SPRINKLERS-OVER 5(EA.) 1.D0
contracts for wch projects with a&ntrectme')licensed pursuant To -
the Cunimetor'sLicenseLaw. SEWER-SANITARY-STORM EA.200ft/8.00 ppb TRACT NO. PARCEL NO,
Ell Ian LacmpTunder Sec. ,B.SP.C.formis WATER HEATER W/VENT 4.00 .Qa
reason
Owner Done WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby a10rm that I have �s{�fiea a of consent In sell-snore• ZONING ENG.SITE N0.
or a cenific.11 firm Insumnee,or a ccrlified
Copy Iheryyf Pab.� aT10
1'olicy NoA Company eNIT .
Q ❑ CeDilicdcopyisherehyfurnished. /' FIRE SPRINK ENERGY T 24
�( Ccrtilie w CI d I ed 1 1 in division.
Z 0 N)6icanl��'�Le 44C a irk MISC.-. REFER TO ORD. y O N❑ Y ❑ N❑
K N' C17RI IFICA'rF OF F,XIiMPTION PROM WORKERS' PERMIT ISSUANCE 6.00 p FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE - P G.C0 4TTR. • LIC.Np, �,'i TPLC
OTAL pO• ❑ ❑ ❑ ❑
CL ❑ 1'I'he, Eceliun need not be completed if the Perin:.a for one / / A oV Y Y N Y N
Z) Z hundred dollars(S100)or1Kss.)
U O 1 certify that in the performance of the work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued,I shall not employ any person in any manner so as to
U becmne subject to the Workers'Compensation Laws of California.
0.WDam ApplieanT ALTER OR ADD TO MECH. q-DD BUILDING
} W NOTICE'10 APPLICANT: If,after making this Certificate of lie-
I-. Z enspticn,you should hocome sobject to the Workers Conslsansation APPLIANCE 4.00 PLAN CHECK
provisions of the labor Code, you muss forthwith comply with FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT ITO 10.000 C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00CENl) 5.00 SEISMICFEE
I hereby afMn that them is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the permarr ance of the work for which this Isomil is issued(Sec. MICROFILM
3197,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Leaders AddHEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
ress
- I certify that l have read this application and estate that lIs:above VENTILATION FAN (SINGLE) 3.00
inlisrmmion a correct. I agrn to vmply with all city and woody PLUMBING
ordinances and state laws slating m building construction,and BOILER-COfJP(3 H.P.or 100,0008.T.U.) 4.00
hereby authorise representatives of the city to enter upon the BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
.how mentioned property for inspection purposes.
(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 ' an way accrue attained said City in consequence of the PERMIT ISSUANCE 3.00
I g epelenit. MECH.CONT. LIC.NO. MECH.
rorAt TOTAL
Siymlure of pliant/Contractor U
OFFICECOPY