6880 APPLICANT TO FILL IN INFORMATION WITHIN RED,LINES.- USE'BALL POINT PEN.ONLY
BUILDING PROJECT I DENT]FICATION• ' PERMIT NUMBER
BUILDING -APPLICATION & PERMIT
nooRK V BUILDING -ELECTRICAL—PLUMBING—MECHANICAL 6880
DY:NFR'S PLAN CHECK VALIDATION
HANE ,�(( (/�/--//'� QTY. ELECTRIC PERMIT - FEE
OD•"('� �/�7L1.ONE
c rvTRAcrons r . UTLETS-SWITCHES-RECEP 5.00/1.
N NT
Lie.No. LIGHTING FIXTURES 5.00/1.00
r ro iRss Acrons . ,TaS IA pp LIANCES-RESIDENTIAL 4.00
A Pl I')
CL (� PANELS S.00 'DATE OF APPLICATION
R ECiSIGNS x,5.110 PLAN CHECK FEE .NO.
R
ENGINEER
' uc)No. . SIGNS TRANS. 3.00
Doo les END 5.00 SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zlv TEMP.METER OR POLE INS.{ 15.00
DDRESS
PMOTORS, SEE FEE SCH.
ADDRESS
SERVICE CHANGE '110.001
Foo _ LICENSED CONTRACTORS DECLARATION -
Q I herbv affirm that I am IlCenxd under provisions o(Chaple,9 E •' ♦ ISSUANCE DATE
FAID '
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
rD,Z I'rofes,iuns C{{�qq nd ny license it in full force and effect." f '
i o=— Lirenx❑a¢LL Lic.Numb.,����{{{{ DEG ' Il{t t ❑ � ❑
Q r Uutc /�CnniracttYf.4
`a x 3 �// - BUILDING PERMIT
¢ ¢ oc < OWNER-BUILDER DECLARATION - INFORMATION
w0¢ O 'I herb dfirm that I am exam t from the Contractor's License MISC.— REFER' IO:ORD
�+uy y' P VALUATION S/FT.
w LL o a Law for the following reason.(Sec.7031.5.Businessand Professions 1 PERMIT,ISSUANCE ' 6,00
Pr C«Ic:Any city or county which requiresa permit to construct,eller,
rt¢a improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. - LIC.N0, ELEC.
D¢ q
rulres the applicant for such permit to file a signed statement that .}.' , TOTAL PERMIT TO
X $ he is licensed pursuant to the provisions of the Contractors License E IT ��
F a a
Law(Chapter 9(commencingwith Section 7000)of Division 3ofihe C
S i o Business end PHT6,1swits Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
u ; —.. by any applicant for a pemhit subjects the applicant too civil Penalty ALTER-DRAIN&'V ENT-WATER (EA.) 4.00
of not more than five hundred dollars(S500)J: -
❑ I,as owner of the property,or my employees with wage's as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their,vile 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 Contractor's License Law does not apply ro an owner of
r property who builds or improves ihemon,and who d«•s such work FIXTURES-PER TRAP 4 so.FT.FLOOR AREA TOTALACREAGE
himself or through his own empinyLcs,provided that such improve-
Rents are not intended or offered for sale If.hawcvcr,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
builder will have the burden of proving that he did not build or in, RES IND CON PB Omar
Prove for Purpose of rule.). INDUSTRIAL WASTE INTER. "20.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed Contractors to construct the project(tire.7044,Business LAWN SPRINKL BS 011jVC 5 V.B. 5.00 ASSESSORS PARCEL N0.
.it Professions Code:The Contractor's License Taw does not apply
to an owner of property who builds or improves thereon,and who ` LAWN SPRINKLERS--OV ER 5(EA.) 1.00
contracts for such projects with o conlracto00 licensed pursuant to
tire Contractor's License Taw. - SEWER-SANIT 'R YST_OR MkEA..2O0ft/8.00 TRACT NO, PARCEL NO.
❑ I um exempt under Sec. ,B.&P.C.foi,this WATER HEATER W/VENT ` 4,00
reao n
Owner Dem WATERSY T I C 4.00 ACC.GATE ACG FILE NO.
.WORKERS'COMPENSATION DECLARATION WATER.TREATING EQUIP, '4.00
I hereby affirm that I have a Cert i Ncate ofemiscat to self-insure, ' ZONING ENG.SITE NO.
or a Certificate of Workers'Co�mlwn/satiioon�]I,n�surancee,,orr a scertified
,copy thou, LScoa3 hf���'
O D Certtined copy isherchy furnished. FIRE SPRINK ENERGY T 24
Z 2 ❑ Certified copy is Bled Willi the city inspection division. ]MISC. REFER-TO ORD:
O Applicant Y ❑ N❑ Y ❑ No
Cli R'I'll'ICA'fEOF IiXEMP'1'ION PROM WORKERS' PERMIT ISSUANCE 6.D0 FLGGDZONE A.L.0 C.
IL > COMPENSATION INSURANCE: ON IC.NO.� PLG. 112 A
CIL O (Phis section need not he completed if the permit is for o« ' ITOT40qa
Y[JNF] .Y ElNEI::) Z hundred dollars IS 100)or less I ,
U O 1 Certify that in the Performance of the work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
U. F mit is issued,I shall not employ any Person in any manner so as to
O
U became soh cct m m the Workers'Consation Laws of California.
w . P
Date A PPlieBUILDING
ant - ALTER OR ADD TO MECH. 4.00
NOTICE TO APPLICANT: IL after making this Certificate of Ex-
F ? amption,you should become subject to the Workers'Compensation APPLIANCE • 4.00 PLAN CHECK
provisions of the labor Code, you most forthwith comply with FEE
U suclh provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1Q000C.F.NL) 3.00
CONSTRUCT ION,LENDING AGENCY AIR HANDLING UNIT(OVER 1OX0C.F.M.) 5.00 SEISMIC FEE
I hereby uIfimr that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the pertomlance of the work for which This permit Is issued(Sec. MICROFILM
3097. .CJ. A`k '�•h � HEATING UNIT IT
100,000 B.T.U.) 4.00
Lender's Name -- HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address. / •
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating t.-building constnaOtion, and BOILER-COW(3 H.P.or 100,000 B.T.U.) 4.00
herby authorize,representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mcntinncd'pr ,ty forinspecfion purposes.
(We) ogee to e, indemnl fy and keep harrmless the City of MISC.- REFER TO ORD.
Cupertino against Zta,S, 'uJgmenm costs and expenses which PERMIT ISSUANCE- B.pO CONST.TAX
ma any ay cLTue I st said City in consequence of the
an t mhi MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL 4 -1
S' oturc oCA mans/Con ctor Datc
OFFICE COPY