4043 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY f �ZpS,
BU I LDING PROJECT I DENTIFICATION
PERMIT NUMBER
BUILDING �O�,R S ����. Ye APPLICATION & PERMIT - A O A
AooR L� L�
A.),"/ BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S - PLAN CHECK VALIDATION
NAME
l +fJ L OTY. ELECTRIC PERMIT FEE
NAP MTRAcrona '91UTLETS-SWITCHES-RECEP 5.00/1.00
SC
Zi0U uc.NO. 2 LIGHTI NG FIXTURES. 5.00/1.00
CONTRACTORS
RACTORs
ADD'
APPLIANCES-RESIDENTIAL 4.00 DATE OF APPLICATION
/ y
OHONE PANELS (3 5.00 ./'
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OP Jr�
ENGINEER
SIC
.NO. SIGNS TRANS. 3.00
ARCRe R ENO. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
y r''r Z 77, % �47IZ TEMP. METER OR POLE INS. 15.00
AEOTORS SEE FEE SCH. //5
ADDRDDRESSSS
SERVICE CHANGE 1''10.00( ' / ,
O o LICENSED CONTRAORS DECLARATION \`
a y b I hcrcby uffinn flier 1 am ii....ed under prop ofChapter) ISSUANCE DATE
Z w
r on.men-in with Section 7000 of Division 3 0l the Rusincss anA
1. i R i BLDG. ELECT. PLG. MECH.
r o i Professions Code sd myY licenLi is
in full fore•a h c"c SA
z o m H.
License Cla�_ l�,y�_J-V Lin.Number
9 z r D Datc_. '.IrS-^J_Contractor
a s - BUILDING PERMIT
Ix w OWNER-BUILDER DECLARATION
w u y I hereby affirm that 1 am exempt from the Contractor's License
MISC.- REFER ORD INFORMATION
uoa Law for the following reason.)See.7031.5,HHonessand Profssinns PERMIT ISSUANCE f 6.00 w VALUATION 5/FT.
� m � �
Code.Any city or county which requires a permit to construct,alter,
T ¢ o improve,denmlish,or repair any structure,prior to its issuance,also ELEC.CONTR. CIC.NO. ELEC. 0>`
O¢ re9eires the applicant for such permit to file a signet)statement that OS�uDfN ^/v TOTAL 6 PERMIT TO
a en m he is licensed pursuant to the provisions of the Contractor's License
F za
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe 4AFj' ELtL /
Business and Professions Code)or that he is exempt therefrom end QTY. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n by any applicant for a permit subjects the applicant mu civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of nut more than five hundred dollars(8500).1:
❑ I,as owner of the property,or my employees with -age,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,AREA,COND. 4.00
Code:The Contractor's License Law does not applyto an owner of
property who builds or improves fiction,and who does such work FIXTURES-PER TRAP 4.00 So.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
inertsarenotintendedoroffered for sale.If,however,the budding GAS-EA.SYSTEM-1 1 NC.4 OUTLETS 4.00
or improvemmnt is sold within one year of Completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will huvc the burden of pry
rshn,that he Aid mit build or inn- RES IND CON PB 00-ii,
Roe fon purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,As owner of the property.am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code The Contractor's License Law does not apply'
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts forsuch projects with it contractors)license(]pursuant to
the Conlractor's License Law. - SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ l:mhexcnhptundcr Scc ,B.&IlCforthls WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
` WORKERS'COMPEN'SA'FION DECLARATION WATER TREATING EQUIP. 4.00
9 1 hereby'uffinn that I have a certificate of crnrsent to set Ginsurc, ZONING
or a certificate of Workers Compensation Insurance,or a TertifieJ ENG.SITE NO.
copy thereof)Sec.3800-Lah.CA
I'ohcy No. Con.puny
❑ Cerlif icd copy is hereby lumished'J/1f/L.f.(I DO1 FIRESPRINK ENERGY T-24
Z
Z ,O Cenif icd copy,is tiled with the 'ty inspection division.
DXC Applicant v T -%" -= G MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
CC y CERTIPICATEOP FXENIPI'ION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOODZONE A.L.U.C.
LU > COMPENSATION INSURANCIi PLG.CONTE. LIC.NO. PLG. V❑ N❑' Y ❑ NEI Z (This stiction red not be completed if the Permit is for one TOTAL
hundred dollars IS 100)or Icss.)
U O I certify mel in the perfomnmce of the work for which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued, I shall not....ploy any person in any'manner so as to
U become subject to the Workers'Con.pmuation Laws of Cahmorhia.
U-1 Drdc Applicant ALTER OR ADD TO MECH. 4,00 BUILDING
} h NOTICE TO APPLICANT: If,after making this Certificate of Es-
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
pmvrsions of the Labor Code, you must forthwith comply will FEE
U such provisions or Iles permit shall be Actilncd revoked. AIR HANDLING UNIT(TO 10,000QF.M.) 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER IOAOOC.F.M.) 5.00 SEISMIC FEE
1 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(See. MICROFILM
3097.CHC.). I HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATI NG UN IT(OV ER 100,000 B.T.U.)7.50 ELECTRIC
I certify thud huvc toed this."plication and slmc tial the above VENTILATION FAN (SINGLE) 3.00
inforniahioa 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 vu0horiee representatives of this city in enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purpnms.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
nwy in any way accrue against said City in consc4ucnoc of 1110
,mining of III
pcnnit. MECH.CONT, LIG.NO. TOECH
TAL
`�.ice 2 ti Sy�t� TOTAL
Signal re Applican Co tractor Dutc
INSPECTOR COPY