5946 1
'APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT lDENTI FICATION PERMIT NUMBER
APPLICATION & PERMIT
ADORING
ADDRESS
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 5946
O NEWS PLAN CHECK VALIDATION
ME - OTY. ELECTRIC PERMIT FEE
T NE
coMERACTOWs UTLETS-SWITCHESx RECEP 5.00/1.00
LIC.ND. LIGHTING FIXTURES 5.00/1.00
CONTRACTORS It PPLIANCES-RESIDENTIAL 4.DO
pDWEss V
PHON PANELS 5.00 DATE OF APPLICATION
W ECTSIGNS 6.00
PLAN CHECK FEE P.C.NO.
On
ENGINEER
LIC.ND. SIGNS TRANS. 3.00
ARCH OR SssENG. SPECIAL CIRCUIT
PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. - 00
APPLICAu
y AO MOTORS . SEE FEE SC
FB a2
SERVICE CHANGE 0.00 fOla�J�'y�
w o o LICENSED CONTRACTORS DECLARATION _
re o u 1 hereby affirm that 1 am licensed under provisions of Chapter 9 A I` - ISSUANCE DATE
az 'a
(commencing with Section 7000)of Uiveio 3 of the Bpslneu and BLDG. ELECT. PLG. MECH.
wi Professions Code,and my license is in full" r cy��
Z,i w W Lian ass Lic.Numbe�-{>v - I y 0 Up2 UI( � � - L IRI
O Dolc�Contnctol���r
Q y j
BUILDING PERMIT
s
y ¢ ¢w OWNER-BUILDER DECLARATION - - - J•,-.>rl
REFER TO ORD INFORMATIONS
t w LL G I for(h affirm that 1 em exempt from the Contimtor's License MISC.- VALUATION ��"
H u O a law for the following reason.(Sec.7031.5,BL messand Professions —PERMIT ISSUANCE 6.00 '� pJ,lL
Code:Any city or county which mquiresa permit tomslstrucl,alter,
! Is Q improve,demolish,or repair any structure,prior to its issuance.also ELEC.CONTR. LIC.NO. ELEG '] P D
1 i O LL r quires the applicant for such Permit to file a signed statement that TOTAL pZ 3 T 1 L V q
whe is licensed pursuant to the provisions of the Contractor's License 9 - Jl
Il- F z a
Law(Chapter 9(commerwing with Section 7000)of Division 3 ofthe - �(,/C7 JIV41 "r'
f i O Business and Profession.Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE'
¢ r$ the basis for the alleged exemption.Any violation of Section 7031.5STORIES } PpylppKRfv
by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.) 4.00
'� aC1 MM
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wag s as BACK FLOW PROTECT.DEVICE 2.00 Oce.GROUP RES.UNITS
} their sok compensation,will do the work,and the structure is not
t intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA COND. 4.00 /
Code:The Contractor's Lice=Law Lina not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 4.00 SQ FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
menti are or intended urolfered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
buiWer,will have the burden of pmving Ihat he did out build or im- RES IND CON PB OWw
prove for purpose of idle.). INDUSTRIAL WASTE INTER. 20.00
s ❑ I,M owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(See.7044,Business LAWN SPRINKLERS-1INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:I be Contractor's License Law'does not apply '
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed purmanl to -
theContractor'sLicenselaw. SEWER-SANITARY-STORM AAr2,00ftmoo TRACT NO. PARCEL NO.
0 am exempt under See. ,tl.&P.C.for this WATER HEATER W/VENT 4,00
reason
Owner Date WATER SYSTEM (1 IL'r-'9.00 ACC.DATE ACC.FILENO.
WORKFRs'COMPENSATION DECLARATION - WATER TREATING EQUIP. .a 4.00
1 hereby affirm that I have a certificate ofemnsenl to self-in sure, 0 I TIRO ZONING ENG.SITE NO.
of a certificate of Workeri Compensation Insurance,or a certified
copy thcmof(Sec.3800,Lib
Policy No. ompan
�' ❑ ( IRI CO
iCs hartby famish¢ FIRE SPRINK ENERGY T34
Z o '
Z ell' d I file w' h t �iry ins action division.
0 Arpficant MISC.- REFER TO ORD. - Y ❑ IN F] Y ❑ N❑
-t fL m CERTIFICATE 01'EXEMPTION FROM N'URKERS', PERMIT ISSUANCE 6.00 FLOODZONE '.A.L.U.O.
MP
LU > . COI!NSWION INSURANCE PLO.CONTR. LIC.NO. P /LG.
0- O (This section need not he completed if the permit is for one TOTAL [:] N❑ Y❑ N❑
Z) Z hundreddollara(SI00),o,Ie.) -
U O 1 certify that in the performance of the work fur which this pr CITY MECHANICAL PERMIT FEE FEE SUMMARY
r LL U mit is issued,I shall not employ any person in any manner so as to
Imcomc subject to the Workcri Compensation Laws of California. /+rte
BUILDING
W, Uatc Applicant ALTER OR ADD TO MECH. 4.00 a
} rn NOTICE TO APPLICANT: 11;after making this Certificate of Ex- _
F_ Z emptier,you
should subject to the Workcri Compensation APPLIANCE 4.00 PLAN CHECK
. 'provisions of the Labor Code, you most forthwith comply with FEE t Q-
U umh provisions or this permit shall be deemed revoked. AIR HANDLMG UNIT(TO 10MC.F.M.) 3.00
'a CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER10 00C.F.M.) 5.00 SEISMIC FEE SO
I hereby affirm that the«,¢a construction lending agency far EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec.. MICROFILM
3097,CIv.0.). HEATING UNIT(TO 100,000 B.T.U.) 4.00 1
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.P.50 ELECTRIC
Lender's Address
• I certify that I have read this application and state that the above VENTILATION FAM SINGLE) 3.00
information Is correct. I agree to comply with all dty and county PLUMBING /.
ari inanms and slate laws mbting to building construction, and BOILER-CONP(3 H.P.Or 100,000B.T.U.) 4.00
hereby authorize representatives of this city to cmer upon the BOILER-COMP I If1ar060 BTU)SEE FEE SCH. MECHANICAL S
above-manti.ec roperty for inspection purposes.
(We) agree t ve, indemnify'mul keep hamOc;. the City of MISC.- REFER TO ORD.
Cupertino .gains bbllitles,judgements, costs and expenxs which CONST.TAX
may in a Y'wi ccme against said City in mnscquence oft PER
ISSUA UpQ 111 3-00
the pe it MECH.CONT. CIC.NO. MECH.
TOTAL TOTAL
Signa re of App'ssnl/Con c r Uate
OFFICE COPY