5475 �?PLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
BU I LDING PROJECT IDENTIFICATION APPLICATION & PERMIT -
g°"GI"` 5475
ADDRESS
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
.OA E 'S PLAN CHECK VALIDATION
NA E _ _ OTV. - ELECTRIC PERMIT FEE
PHO,N✓E
eANIEnncrons , ON Mis•- OUTLETS-SWITCHES-RECEP5:00/1.00
LIGHTING FIXTURES . 5.00/1.00
.Y;°NpE` T0n3 - )fix APPLIANCES-RESIDENTIAL 4,00
y
PHON 4'�.i PANELS 5.00 DATE OF APPLICATION
ARDHIrE r SIGNS 6(30 PLAN CHECK
DR FEE .C.NO.
ENGINEER
, - LIC.No. SIGNS TRANS. '3.00
nooniss ENG' SPECIALCIRCUIT 5-00 PERMIT VALIDATION
trp EMP.METER OR POLE INS. 15.00
DDREANr's
a /,.., �D MOTORS SEE FEE SCH: f
ADDRESS N'fU
SERVICE CHANGE 10.00
e�ACI
woo LICENSED CONRACFORS DECLARATIONu v I hereby affirm that I am licensed Ruder provisionsf Chapter 9 DATE
N (commencln with Section 7000)of Division 3 of the Business and
¢a 8 BLDG. ELECT. PLG. .MECH.
H o i'- 'I'mfieaions Code,and my license is in full fore a d c e 1. ❑ ❑ O
Lic
e
nsIe,C Lie.Number.
4 z f D ate t �'�Ci.ContractorIf
BUILDING PERMIT
¢ o a OWNER-BUILDER DECLARATION INFORMATION
wI hereby ffirm that I nm exempt from the Contractor's License MISC.- REFER TO ORD
3 u yes P VALUATION S/FT.
F u
0.4 Law for the following reason.(Sea 703 1.5,Business and Professions PERMIT ISSUANCE 6,00
Code:Anycity orcounty which mquiresa permit loconstruct.alter,
QQ ¢ pimprove, or Npalranystrudum,prunto its ionmri ti.stso ELEC CONTR. LIC.NO. ELEG ,
ce o u 1 reclaims the applicant for such permit to file a signed statement that TOTAL PERMIT TO
u w$ he is liccnwd pursuant in the provisions of the Contractors License
F a¢ Law(Chapter 9(commencing with Section 70001of Divixxm3 ofthe .wYl7i
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
. 10 the hasis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n ; _ by any applicant forapennit subjectsthe applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4-00
of not more than five hundred dollars(S500).):
❑ I,as owner of the propsny,or my employees with wager as BACKFLOW PROTECT. DEVICE 2.00 45C.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:The Contractors License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 Sa FT,FLOOR AREA TOTAL ACREAGE
. himself or through his awn employ..provided that such improve-
memsamnotintendedorofferedforsale.If,however,the building GAS-EA-SYSTEM-1 INC.4OUTLETS 4.00
or improvement is sold within one year of completion, the owmn- GAS EASYSTEM-OVER 4 IEA.) T,00 BUILDING USE
builder will have the bis Nen of graving that he did not build or ins - .- - RES IND CON PB Oihn
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the prapudty,am exdusively contracting with ❑ ❑ ❑ ❑ ❑
liccrt contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORSPARCELNO.
and Professions Code:The Contractors License Law does not apply
to an owner oI'property who builds or improve,themon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for,such projectsewilh a centotelogs)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA,200ft/6.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec. ,B.&P.C.for Ibis WATER HEATER W/VENT 4:00
reason
Owner Date ' WATER SYSTEM 4.00 ACC.DATE ACC,f ILE NO,
WORK ERS'COMPENSATION DIiCLA RATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy It "J,e 3S . hr.). '-'w 7�S .
Policy No,�' dny-E kh GI+�raMA+ I -
❑ Cerll red copy in rC eby fun ishet - FIRE SPRINK ENERGY T-Y4
Z 2 ❑ Certified wpy is fl ( city inspection division.
❑ Applicant(, MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
~ w PERMIT ISSUANCE 6,00A�Lo aL.UC.
❑$kTIFICATEOf:X. 11'I'ION PROM WORKERS'LLI > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. v❑ N❑
Z -('this section need not be completed if the permit B for one TOTAL
hundred dollars(5100)or less.)
C1 O I certify that in the performance of the work for which this per. OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL f mit n issued, Ishall not employ any person in any manner so as to
U hccmnc subject to the Workeri Compensation laws Of Cahfornu.
d Date-Applicant ALTER OR'ADD TO MECH. q,pp14
-- BUILDING
>_ to NOI WE TO APPLICANT: If,after making this Certificate of pix..
F 2 empt ion,you should bemnie subject to the workers'COinpenec tion APPLIANCE .00 PLAN CHECK
provisions of the IaMx Code, you nmst forthwith comply with FEE
U, such provisions or this pennit shall M:deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONsrRUCI'ION DEN DINOAGENCY AIR HANDLING UNIT(OV ) SEISMIC FEE
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.). HEATING UNIT(TO 100,
Lenders Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I Certify that I have read thisapplicmion and m scathat the above VENTILATION FAN (SINGLE) 3.00
�.
in
formation'is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-CONPI3 H.P.or 100,000B.T.U.) 4.00
hereby authorize mpresematives of this city to enter upon the BOILER-COMP (Iver 100.000 BTU)SEE FEE SCH. MECHANICAL (O 6
above mentioned properly for inspection purposes:
(We) agree to save, indemnify and keep hi moles the City of MISC. REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way a rue 'Inst said City in wnsequence of the PERMIT ISSUANCE 3,110 1..3
grantingafthi/se L . MECH.CONT. LIC.NO. MECH.L
Glomi y ��__& %,TATOTAL
Signatumof ppB raDate
nt/Contctor e
OFFICE COPY '