3291 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT FICATION RMIT NO ER
BUILDING APPLICATION & PERMIT_ _ 3291
ADDRESS /D/21
�` D �, BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VAL,19ATION
NAME. // DTV. ELECTRIC PERMIT FEE D
°. 14,
h �{e nPi (J
co TRACTDRs UTLETS-SWITCHES-RECEP 5.00/1.00
NAME 99/��,}
IC.ry V-g LIGHTING FIXTURES 5.00/1.00
CON i FACTOR's'
ADDRESS 'X 3:S APPLIANCES-RESIDENTIAL 4.00
- PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT - - , SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
pDRESS ENG, - SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH:
ADDRESS
SERVICE CHANGE 10.00
o ¢ z
Foo
L I C F.NSED CONT RACI'ORS DECLARATION,
¢ U I Imurby affirm 111:1[ I-HIII licensed under provisiolrs Of Chapter 9 ISSUANCE DATE
^y Q m (commencing with Section 7000)of Division 3 of the Business and - p ELECT. PLG. MECH,
F 0 z Professions Code,and my license is in full force and effect. -� ❑ ❑ ❑
z o P, - License Class Lie.Number
9 Ps- O Ps 1) Contractor
Q y s I BUILDING PERMIT
¢ ¢ w a OWNER-BUILDER DECLARATION INFORMATION
040 MISC.- REFER TO ORD
w ; LL H I hereby affirm that 1 am exempt from the Contractor's License VALUATION 5/FT.
FLL0< Law for the following reason.(Sec.703 I.S.Businessand Professions PERMIT ISSUANCE 6.00 /
Codc'.Any city or county which requires a permit to construct,alter.ac Q �/
¢ ¢ improve,demolish,nr repair any stnmtdre,prior lo,i[s issuance.also ELEC.CONTR. LIC.NO. ELEC. J J"D
'
G u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
Is
m he is licensed pursuant to the provisions'oflhe Contractor'sLicense
i
Law(Chapter9(commencingwill Section 7000)of Division 3 of(be
L a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE ;poor_
¢ IT- c Ihu basis for the alleged exemption.Any violation of Serum,7031.5 STORIES -TYPE C rvSTR.
more than
n ; m by any applicabtfora permit subjects the applicant loacivil penahy
of nALTER-DRAIN&VENT-WATER (EA.) 4.00 / }�N�I.
ot five hundred dollars 15500)):
❑ 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.-DEV ICE 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 apply to an owner at - '
property who builds or improves thereon,and who docs such work F IXTURES-PER TRAP 4.00 SO.PT.PLOOH AREA TOTAL ACREAGE
• himself re through his own employers,provided that such improve-
memsare through
ughhis onemployeesale.ovided at Suheniproig GAS-EA.SYSTEM-1INC.4OUTLETS 4.00
or improvement is sold within one year of completion,file owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 B ILDING USE
bulder will have the burden of provingthat he did not build or ire-
Provo for purpose ofsale.). INDUSTRIAL WASTE INTER. 20.00
RES CON PO Coil,ElI,a r Of tin property.and cxcl...Rely c.utm,tin,with ❑ ❑ ❑ ❑
licensed contractors to cmmtowt Ihr project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5-00 ASSESSORS PARCEL NO.
and Professions Coda:The Contractor's'License Law does not apply
to an owner of property who builds or iiiproves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.I 1.00
w contracts far such projects with a conracmtlrc)licensed pursuant to '
the Contractor's License Law. , SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ -1 am exempt under Ser.-,B,&P,C.,tier this .WATER HEATER W/VENT 4.00
"s reason
Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
siLlit75IIRIt� 6Z'
WORKERS'CO,MPENSA'I ION DECLARATION WATER TREATING EQUIP. 4.00 .
I hereby affirm that I have a certificate ofcmncir to self-insure. ZONING -ENG.SITE NO.
or a certificate of Workers'Compensation Insurance.or a certified -
copy thereof I Sec,3800,Lab CA
Policy No - Company _
0 ❑ Certified copy is harcby turni,ahcA. FIRE SPRINK ENERGY T-24
C) A❑heCertlflcd copy is filed, with flue city inspection division.C) - REFER TO ORD. Y ❑ N❑ Y ❑ N❑
MCERTIFICATE OF EwiMPIION PROM WORKERS' PERMIT ISSUANCE 6.00 - FLOOD ZONE A,L.uc.
Lu > CO.4I4NSATION INSURANCE' PLG.CONTR. LIC.NO. PLG.
tY U (This section need not be completed if the permit is for one - TOTAL Y❑ N❑ Y ❑ N❑
Z) Z hundreds llars(S 100)or les,,)
U O 1 certify that in the performance of the work fur which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL /- mit is issued.1 shall not employ any person in any Dimmer so as to
U become subject to the Workers Compensation Laws of California. JHd
Go Datc - Applicam ALTER OR ADD TO MECH. 4.00 BUILDING 9
} to NOTICE TO APPLICANT: It,alter making-Ihis Certificate of Ex-
Z enpion,you should become subject to the Workers'Compensation APPLIANCE 4-00 PLAN CHECK
provisions of the Labor Code, you most hn't11with comply with FEE
U such provisions or this permit Shall he deemed revoked, AIR HANDLING UNIT(TO 10)000C.F.M.) 3.00
CONSI'RUC'1']ON LENDING A(;BNCY AIR HANDLING UNIT(OVER 10)D00C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2A0
the
I)CHO.C)nce.of the work for which this permit is iYSLm&(Sea MICROFILM
CivHEATING UNIT (TO 100,000 B.T.U.) 4.00
Leder's Add - HEATI NO UNIT(OVER 100,000 B.T.U.)7.50
Leader's Address ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information IS correct.I s totaling
cool Ply with all city and county' PLUMBING
ordinances mid state lows relating to building l city and co and BOILER-COMP(3 H.P.Or 100,000 B.T.U.1 4.00
hereby aultion7c representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purpose
(We) agree to save, indemnity and keep harmless the City of MISC.- REFER TO ORD.
r Cupertino against liabilities,judgments. costs and expenses which CONST.TAX
-y in nny way accrue xgai nsl s,id City in consequence of the PERMIT ISSUANCE - 3.00
gr sting of Ihis permit MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL *12.
'ignature of A pphcant/Contractor Datc
OFFICE COPY