5072 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY ,
-'BUI LDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT �O"f�
A00 5 f
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL '
-- -- - -
owNER'S n // PLAN CHECK VALIDATION
ELECTRIC PERMIT FEE
/
L CONT ACTORS C! S OUTLETS_-SWITCHES-RECEP 5.00/1.00
711- rva A/,v /�jtl LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00 -
ao �
o � /
Clw/ o PANELS 5.00 GATE OF APPLICATION
ARCHITECT 6.00 PLAN CHECK FEE P.C.NO.
OR _ SIGNS
ENGI
LIC.No. SIGNS TRANS. 3.00
ARCREOREN - SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP. METER OR POLE INS. 15.00
APPLcANT' MOTORS SEE SCH.
aoOR E F1 (y,
SERVICE CHANGE 10.00
O o LICRNSED CONTRACTORS DECLARATION
< v u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANC DATE
N a vaui (Commencing with Secl/"m 7000)of Dirision 3 offhe Business and G. ELECT. PLG. MECH).
Professions Codq((Iny1,QkQlicen Liis infall�X'-t�
z D m - raise Class_ /%L Lic.Nmnbe - ❑ ❑ ❑
4 so I- w Date Contractor _
a y s J BUILDING PERMIT
¢ ¢ w a OWNER-BUILDER DECLARATION INFORMATION
w ;a, R I hereby affirm that I ant exempt from the Contractor's License MISC.- REFER TO ORD
LLo4 Law1'or the following reason.(Sec.703 L5,Business and Professions PERMIT ISSUANCE 6.00 VALUATION 5/FT.
a Code:Anyenyorcounty whiehrequiresapennittoconstrucLalteL
at Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. EL C... Iwo
ac
O ¢ requires the applicant for such permit to file a signed statement that TOTAL' PERM T TO
e w m" he is licensed pursuant to the provisions of the Contractor's License
Uzi law(Chapter 9 fcommencing with Section 7000)ofDivision 3 of life ,Is / -
Business and Professions Cock)or that he is exempt therefrom and GTY. PLUMBING PERMIT FEE
R r o the basis for the alleged exemption.Any violation of Section 703 L5 STORIES TYPE CONSTR.
d ;mby any applicant fora permit subjects the applicant wacivilpenalty gLTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars 0500).):
❑ I,as owner of the property,or my employees 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,AR EA,COND. 4.00
Code:The 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 TOTAL ACREAGE
• hicrIs re otinithhls ownemred for
pmH.tiol,d hat Such improve- GAS-EA.SYSTEM-I INC.4 OUTLETS 4,00
meats are not intended or offered fir x:do.IL hnwcvcu the building
or improvement is sold within one year of the didlion,the owner. GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
proveof will have the burden of proving that he did not build or in - RES IND CON PB Drier
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 Cl [__1 ❑ F-1 El
as owner of the property,lien exclusively contracting with
licensedd coior,Cod to c Contra the project(Sec, 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and an
rI Cade. ty who
builds o hoproe Law does not who -
to tr owner o1'property who builds or intoms)ce Ihcrenn,and who LAWN SPRINKLE RS-OVER 5 IEA.) 1.00
contracts for such projects with a comrucmrtsl licensed puralmnt to
fife Contractor',License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ Inti exempt under Sett. .BAP.C-to,flux on T-WATER HEATER W/VEN4.00
Dam Owner WATER SYSTEM 4.00 ACC.DATE ACD.FILE NO.
W'ORKRRS-COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that 1ha, e a certificate of canal 1.sell-insure' ZONING - ENG.SITE N0.
or a cernficajyyjj1xggqqq3 of Workcrd ... pensalion Insvaoc�r a ccrh1wd
copyP heyere -
0ed o hcrcb fmin / FIRE SPRINK ENERGY T 24
Z Z Certifi on division. MISC.- - -.REFER TO ORD. ❑ ❑ ❑ N E]0 Applicant_ /" Y N Y -
� N CER'1'IFICATEOFFNENIPI'ION FROM WORKERS' PERMIT ISSUANCE - 6.00 FLOOD-ZONE A,L.U.C. .
LU > COMPEN'SATION INSURANCE PLG.CONTE. LID.NO. PLG. V N Y N
CL 0 (This section need nor bo completed if the permit is for one - TOTAL ❑ ❑ ❑ ❑
2 hundred dollars 151 )or less.) o '
U O I certify th the performance of tire work for which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL P mit is issue nail not employ any person in any manner so as to
U become cr lithe Workers'Compensation Laws of California.
0 w Date- Applicant - BUILDING 1,7 S�
a ALTER OR ADD TO MECH. 4.00
} h NOTI O APPLICANT: 11,after making this Certificate of E,-
eruption,you slmuld become subject m the Worker,Compensm ion APPLIANCE .4.00 PLAN CHECK /
provisions of the Labor Code. you most forthwith comply with FEE (/ 37
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY
AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby arfirnl that the v is a construnion binding agency for EXHAUST HOOD (WITH DUCT) 2.00 -
the performance of
irk for which this Permit is issued(Sec. HEATING UNIT (TO 100,000 B.T.U.) 4.00 MICROFILM
3097.CiYCJ.
Loader's Name HEATI NG UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Addis
I certify tietl have reed this application and,mute tact the abuse VENTILATION FAN (SINGLE) 3.00
0 hournmtion is correct.1 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 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) agree m save, indemnity and keep harmless the City of MISC.- REFER TO ORD.
Cupertino-against liabilities,judgments, costs and expenses which CONST.TAX
may in y accrue.against sa City in eonseyucnee o the PERMIT ISSUANCE 3.00 .
unit, f i MECH.CONT. LIC NO. MECH. 7
TOTAL TOTAL a 3
Sigua�ant/Contractor Dutc
OFFICE COPY