6851 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENT]FICATION
PERMIT NUMBER
.DILDIrvG APPLICATION & PERMIT
u ADDRESS ypy�p Towti CT/1 4,o,,,G 6851
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
P
OWrvER' PLAN CHECK VALIDATION
•"� NAME _ QTY. ELECTRIC PERMIT FEE
HON
NAAW croRs UTLETS-SWITCHES-RECEP 5.00/1.00
NAME
), /1` _Al .No. LIGHTING FIXTURES 5.00/1.00
DRRAcroRs
ADDRESS PPLIANCES-RESIDENTIAL 4.00
AO
PHON PANELS 5.00 GATE OF APPLICATION
A CHIT T SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
-,; sec.rvO. SIGNS TRANS. 3.00
moo ESS 17:eN SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
oze qDaain1z1,Mt TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
=�• SERVICE CHANGE 10.00 i-
f
_00 LICENSIiD CONTRACTORS DECLARATION
ar U v I hereby affirm Ile( 1 am licensed under Provisions of Chapler 9 ISSUANCE DATE
N G y (colon¢acing with Section 7000)of'Division 3 of the Business and x FLOG. ELECT. PLG. MECH.
,-, N z• 1'Intcsions Co dc,:1n I n hcnhsc is in full I'or•:c 'd it ❑ ❑ ❑ ❑
`z O H Daen lass_('-/�/ CohGumberA y
r o DaeContmaor ;ty(p�{
� �C�/ BUILDINGINFORMATION w a OWNIi R-BUILDER UECLIA/1'1KA - INFORMATION
woACom' MISC.- REFER TO ORD
oIi 1 hcrohy alfirm Ilial I .m cxmnpt lion the Contr;mloPs�Cellsl` VALUATION $/FT.
H .. o A . Law for the following reason.(Sec.7031.5,Business and professions PERMIT ISSUANCE 6.00 pJ
-
MV, d Cock:Anycity orcounty whichreqoiresapermil to construct,alter, 'j 5O0 r
ac Q 4 0 improve,demolish,Or repair any Structure.prior tO its Issuance,also ELEC.CONTR. LIC.NO. ELEC.
it
K !cliches the applicant for Such pert..it to file a signed Statement four TOTAL PERMIT TO
Ci K
m U. he is licensed pursuant to the provisions of the Contractors License
Hzi
Law(chapter 9(conmrencingwith Section 7000)of Division 3o1 the
Fi o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE �•1
Ix o the basis for the alleged exemption.Any violation of Section 703 L5 STORIES TYPE CONSTR.
A T by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred Dollars(5500).7: ALTER-DRAIN&VENT-WATER (EA.) 4.00
❑ 1,as owner of lite property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2,00 oce.caouP RES.UNITS
.sole compensation,will do the work,and the structure is not
intended or offered lir sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:'fie Contractor's License Law does 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 -TDTAL ACREAGE
. himself or through his own employees.provided that Such im
mnprove-
mesarootintendedorofferedforsale.if,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
or improvemmut is sold within one year of completion,the own'
- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or inir- RES IND CON PF Omar
'prf ove for purpose osale.). INDUSTRIAL WASTE INTER. 20.00 El ❑ ❑ ❑ 0
❑ 1,as owner of the properly',am exclusively'contracting with
licensed contractors to construct the project(Sec. 7044,Bo9nesS LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professfuns Code:'I'he Contractor's License Law does not apply
to:lie owner of pngsUy who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for Such projects with a contruclons)licensed pursuant In
the Contractor's License law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT No, PARCEL NO.
❑ l um exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 4.00
son
Uwner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORK Ii RS'COM 1'YNSA""PION DECLARATION WATER TREATING EQUIP. 4.00
I hereby alfirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
1
rohropy thereof(Sce.3800.LaM1 C.).
cy No. Company ('A(. , ie'kmP, _
O ❑ Cortiltad c q.y is thereby'famish cdi FIRE SPRINK ENERGY T 24
Z,2-,4 (�ficd fly Is led will t- city inspection division.
O Applicant '! 4l MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
= CE RTI FICA 1'1:0_1:EX ON FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
W > COMPIi NSAT'ION'INSURANCE PLG.CONTR. LIC.NO. PLG.
(This section need amt he completed if the permit is ❑r o, TOTAL Y❑ NNE] Y E] NE]
2
handled dollars IS 100)or Tess.) e
U O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- not is issued,I shall not employ any person in any manner so as to
become subject to the Workers'Con.pensatlon Laws of California.
O w BUILDING
0. Dat° Applicant ALTER OR ADD TO MECH. 4.00
} V) NO'IICI! '10 APPLICANT: if,after nuking this Certificate Of fix-
(_ Z engnion,you should become subject to the Worker Conipensat ion APPLIANCE .4,00 PLAN CHECK
I'll of the: Labor Code, you must forthwith comply with FEE pC.
U "tell provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.NL) 3.00
CONSI'RUC1'ION LENDING AGENCY AIRHANDLING UNIT(OVER 10PMC.F.M.) 5.00 SEISMIC FEE d�
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.L HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name H EATI N G U N IT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I have read this application and.state[flat the above VENTILATION FAN (SINGLE) 3.00
• information is correct, I agree In 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 authorin• representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned Property for inspection purposes.
(We) .gree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judg...ents, costs and expenses which CONST.TAX
may in any way accrue against s ity in consequence of the PERMIT ISSUANCE 3.00
granting of thispe / MECH.CONT. LIC,NO. MEETAH.
`SigTature o ppli an/Co TOTAL actor )ate -
INSPECTOR COPY