7114 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING
APPLICATION & PERMIT ,
AUURE55
"l, J69100 V 7ANM(1
f BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 7114
ry PLAN CHECK VALIDATION
rvAME CITY. ELECTRIC PERMIT FEE
.. ` r 0
SIC. PHONE ^
AME croRs
NOUTLETS-SWITCHES-RECEP 5.00/1.00
NAME
LIC.NO. LIGHTING FIXTURES 5.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECTSIGNS 6.00 PLAN CHECK FEE P.C.NO.
On
ENGINEER
LOC.NO SIGNS TRANS. 3-00
AARCH.OR
DDRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 15.00
j APPLICANT'S MOTORS ' SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10-00
0. O LICENSP.D CON'I'RACI ORS DECLARATION
a U v I hereby Affirm that I in licensed under pN,viiiinis of Chapte,9 W6117114CE DATE
m rt to
(commencing with Section 7000)of Division 3 of the Business and - LOG. EL PLC. MECH.
r z Professions Cade,and my license is in full force and effect. ❑ ❑
z o m License Class Lie Number
Q z O 1),ne Contractor
PE ,
w OWNER-BUILLER DECLARATION � G PERMIT
REFER TO ORD INFORMATION
X ;LL m I hereby affirm Ota[I am exempt from the Contractor's License MISC.- VALUATION S/FT.
r .. 0< Law In,the following Leaven.(Sec.7031.5.Bmmcssand Poofessians PERMIT ISSUANCE 6.00
Code:Any city or county which ot,rines a permit to construct,alicq
a, Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
o w m, requires the applicant for such pernit to file a signed Statement that TOTALso PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License /
F, zQ
Law(Chapter 9(commencing with Section 70000of Division 3 oflhc
4 O Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
M I-o the basis for the alleged cxemptioulAny violation of Section 7031.5 STORIES TYPE CONSTR.
ar any applicant for a permit subjed5 the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars($5000.):I A by❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
114ir sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and I'mfesions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:'fine Contractor's License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 4.00 so.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
Or improvement is sold within one year of completion,the owner GAS-EASYSTEM-OVER 4 IEA) 100 BUILDINGUSE
builder will have the burden of proving that he did nor build or im- . . .
RES IND N PB Omer
prove farner ofsthep INDUSTRIAL WASTE INTER. 20.00 El .❑ ❑ El
I,ase owowner of the property,am exclusively contractingwith
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESS ARCEL NO.
mid'Professions Code:The Contractor's License Law docs not apply
;tit am owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA-) 1-00
hmfaels rtnuct ",License
ts Lwitlhacontmnorls)licensed pursuant In SEWER-SANITARY-STORM EA.200ft/8.00 TRAC NO. PARCEL NO.
�1Le�'oI am exci License Law.
I um exempt under Sec.-,B&P.C.for Ibis WATER HEATER W/VENT 4.00
n' n
Owner Dale WATER SYSTEM 4.00 ACGDATE ACC.FILE NO.
�\
woRK1iRS'coMPlirvsAnoN nitcleRnnoN WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certifhcale ofconsent to sol Finsure, ZONING ENG.SITE NO.
certificate of Workers'Compensation Insurance,or a certified
copythereof(Sec.3800,I.ab.CJ-
policy Nr, Company
O 0 Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z 13 Certified copy is filed with the city inspeclion division. MISC.- REFER TO ORD. ❑ N C] ❑ N❑
Applicant Y V
y CERTIFICATE OF li%IiMI'fION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.0 c.
LU > COMPENSATION INSURANCE PLD.CONTE. LIC.NO. PLG.
CL O ('Phis section need not be completed if the permit is for one TOTAL Y❑ IN Y❑ N❑
Z) Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mil is issued,I shall not employ any person in any manners,as to
U become subject to the Workers''Compensation Laws of California.
O n Data Applin°ant ALTER OR ADD TO MECH. 4.00 BUILDING
} m NOTICE 70 APPLICANT: If,after making this Certificate of Ex-
Z crnptlon,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
Provisions of the Labor Code,.you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONS'(RUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10p00GEM.) 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. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lenders Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is eorrecC 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 rcprseuDdives of this city to cmc, .,,on the BOILER-COMP(Over100ooOBTU)SEEFEESCH. MECHANICAL
above menhoned property for inspection purposes.
(We) agree to Save, indemnify and keep harmless tiro City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, cost,and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
grueling.1/1 ,pcnniL MECH.CONT. LIC NO. MECH.
� ? TOTAL TOTAL
Sign eofA cant/Co traclor Date
INSPECTOR COPY
N r.