4631 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT i DENTI FICATION PERMIT NUMBER
/ BUILDING APPLICATION & PERMIT AI �
T ADolji Irl cuuab b BUILDING-ELECTRICAL-PLUMBING -MECHANICAL Lr 3
-OWNERS - PLAN CHECK VALIDATION
�� NAME QTY. ELECTRIC PERMIT ^FEE
C7 M I E PHONE
CONTRACTOR R 253 321
DRs
NAME crUTLETS-SWITCHES-RECEP 5.00/1.00
NAME
LIC,NO. LIGHTING FIXTURES 5.00/1.00
CON REScroRs
ADDRESS
DDAPPLIANCES-RESIDENTIAL 4.00
OOTRA
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT - SIGNS
6,00 PLAN CHECK FEE P.C.NO.
On
ENGINEER -
_ - 'IC.NO, SIGNS TRANS. 3.00
ADDRESS eNa SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
APPLICANTS
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
o o LICENSIiD CONTRACTORS DECLARATION
a U u I lereby affirm Ihat I am licensed under provisions of Chupler 9 ISSUANCE DATE
y Q m (commencing with $rctiOn 7000)of Division 3 ol'the Business:lad BLDG. ELECT. PLG. MECH.
H m z Professions Code,and my license is in full force and effect. _ ❑ ❑ ❑ ❑
z 0 u, - License Class Lie No...be, -
o w - O' Date- Conlmctor
a m f I - BUILDING PERMIT
¢ ¢ w a .OWNER-BUILDER DECLARATION ^ . INFORMATION
oA ° MISC.- REFER TO ORD
X
a- u H I hereby affirm that I'am exempt from the Contraclur's Li,ce,c 'PAID.
$/FT.
H u o¢ Law for the following reason.(Sec 7031.5,Business unJ Professions PERMIT ISSUANCE 6.00 r^w
Code Any City or county which requires a permit to construct,alter, _ L��7 /�
¢ R¢ 0 improve,demolish,or repair any structure,prior to its issuance,also FLED.CONTE. LIC.NO. ELEC. / / `�
- 0, requires the applicant for such permit m file a signed statement that .TOTAL E T
u w m he is licensed pursuant to the provisions of the Contractor's License NOV
H z i Law(Chapter 9(commencing with Section 7000)of Division 3 of the 003 S-rldk/(r
4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ H m the basis for the alleged exemption.Any violation of Section 7031.5 I Rpe I�'PE CONSTR. --
i ;_- by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(S50(i
❑ 1,as owner of the property,or my employees with wages as _ BACK F LOW PROTECT.DEVICE 2.00 DCO.GROUP HES.unlTs
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,AR EA,COND. 4.00
Coder The Contractor's License Law docs not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 s0.FT FLOOR AREA TOTAL ACREAGE
himself or through his own employees,prosided that SUClm improve-
mems areno,jntcndCd or offered for sale.If,however,the building GAS-EA.SYSTEM-1•INC.40UTLETS 4.00
or improvement is sold within one year.of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
1 builder will have the burden of proving that he did Hot build or im-
prove for purposeofsale.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB Omar
❑ 1,as owner of the property am exclusively connoting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct tile project(Sec. 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 5.00 -ASSESSORS PARCEL NO.
and Professions Code:The Contract.,',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 contractuds)licensed pursuant to
the Co Far clot's license Law. - SEWER-SANITARY-STORM EA. 200ft/8.00 TRACT NO; PARCEL NO.
-❑ lamexempt'li Sec .B.&P.C.for fills WATER HEATER W/VENT 4.00
reason
WATER SYSTEM ' 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSAT]ON DE:CLAR 'ION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of Consent to Sint-i .....
or a certificate of Workers'Compensation Insurance.or v eerifictl ZONING ENG.SITE NO.
Copy Ihureof(Sec.3800.Lob.C.).
Policy No Company
O • ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T 24
O Certified copy is fled wfth file city inspection division.
ZZ MISC.- REFER TO ORD.
� O Applicant '• Y ❑ N❑ Y ❑ N❑
CCN CIiR'fIPICATfi OF EXEMPI'IUN EkOM N'ORKIiRS' PERMIT ISSUANCE 6.00 PLODD IN
ALu c.
>_ COSIPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d O (This section need not be completed If the permit is for one _ TOTAL Y❑ N❑ Y❑ N❑
2 hundred doll...IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTV MECHANICAL PERMIT FEE
0 FEE SUMMARY
LL H- mil is issued,1 shall not empty any person in any manner so as to
U become subject to the Workers'Compensation Laws of California. /O' Qti
y Dae - Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} rn NOTICE TO APPLICANT. If,after making this Certificate of Ex-
2 emption,you should become subject to the Workers Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you Crust forthwith comply with FEE CO
U .oilprovisions or this permit shall be deenn-d revoked. AIR HANDLING UNIT(TO 10)000C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IO)000C.F.M.) 5.00 SEISMIC FEE SD
I hereby afirms that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
file performance of the work for which this permit is issued(S,c. HEATING UNIT IT
100,000 B.T.U.) 4.00 MICROFILM
3(1 Civ,C.L '
Lender's N:unc HEATING UNIT IDV ER 100,000 B.T.U.17.50
Lcndcr's Adders ELECTRIC
1 certify that 1 have read misapplication and slate the the above VENTILATION FAN (SINGLE) 3.00
fnfonnarm n correct.l I agree to to building with III ity u and county PLUMBING
Nl..antes and stat doses re t ng m ywihantro Y co and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
aby authorize rpesenlativs of, this city to enterpon the BOILER-COMP 100,000 BTU)SEE FEE SCH. MECHANICAL
o vc m ntorad property for inspection I urpose
(We).agree to save, indemmfy and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses whichCONST.TAX
in any way acenUe galnst said City in aoosequcnec of tie PERMIT ISSUANCE 3.00
gr Cling >I this permit. - MECH.CONT. LIC.N0. MECH.
\7s �_� - TOTAL TOTAL 170
Applicant Co actor Datr
OFFICE COPY
j
if