C5705 /APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT 5705
ADDRESS Ongss/ / BUILDING-ELECTRICAL-PLUMBING-'MECHANICAL
OWNER'S - - •. PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
-� ONE
NAME croR's OUTLETS-SWITCHES-RECEP 5.00/1.00
NAME p
44
sec.NO. p O LIGHTING FIXTURES 5.00/1.00
ENT
RE ACTOR's APPLIANCES-RESIDENTIAL 4.00
AOOR ss S419 f Z
PHONE PANELS 5.00 DATE OF APPLICATION
OR
SIGNS 6.00 PLAN CHECK FEE P.C.N0.
ENGINEER
LIC.No. SIGNS TRANS. 3.00 !.
ADDRESS ENc' SPECIAL CIRCUIT 5.00 f v�gp�T�IDnrION
ZIP EMP.METER OR POLE INS. 15.00 �f1
APPLICANT..."'SSAIll A5. MOTORS SEE FEE SCH. TUN 21985
ADDRESS SS J
QJ SERVICE CHANGE 10.00
0 0 o LICI>NSEU CONTRACTORS DECLARATION city of ino
<u 0 _ 1 hereby affirm that 1 am licensed under provisions of Chapter') ISSUANCE GATE
(commencing with Section 7000)of Division 3 of the business and G. ELECT. PLG. MECH.
Fm i 1'rol'essions Code, d t y' ease is in full Wrc," f I ❑ ❑ ❑
rz o m License lass _ Lie.Number ,
-yUutc Contractor
-a ..j BUILDING PERMIT
¢ ¢ ar w u OWNER-BUILDER I NRA'I'I INFORMATION
d o a MISC.- REFER TO ORD
w ; LL rr I hereby affirm that I no exempt from the Contra,un,License VALUATION 5/FT.
F LL o J Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00 nM/l
Em> E Code:Any city or county whiehrequireea permit to construct,alter, ELEC.CONTR. LIG NO. rW
¢ ¢ Q O improve,demolish.or repair any structure,prior to its issuance,also ELEC.
E O LL. requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n m he is licensed pursuant to the provisions of the Contractor's License
FzLa i Law.(Chapter 9(commencing with Section 7000)of Division 3 of the
¢ o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE IC71,�
¢ r es the basis for the alleged exemption.Any violation of Section 7031.5 STORIES OPE CONSTR.
eu per _ by any applicant for a permit subjects the applicant toss civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(S500).):
❑ 1,as owner of the property,or my employees with wages 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 apply to an owner of
property who builds or improves thereon,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'in
prove-
men¢are not intended moffercd for sale.If,however.the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner GAS-EASYSTEM-OVER 4 (EA) 100 BUILDING USE
builder will have the burden of proving that he did not build or ice . . .
- RES IND CON PR Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ 1,as owner of the property,am exclusively contracting with 1 ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:'I'he 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 pursuant m
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO..:- PARCEL NO.
❑ I as,exempt under Sec. .tl.&P.C.for this WATER HEATER W/VENT 4:00
reason
Owner Date WATER SYSTEM 4.00'' ACC.DATE ACC.FILE NO.
c ,
WORK FRS'COMPENSA1'JON DECLARAT[ON WATER TREATING EQUIP. 4.00
I hereby affirm that I have a pens tion of consent to sed-insure. ZONING ore tld¢atn f Work c Compensation Insuranc ora r)'(IcA - ENG.SITE NO.
copy ther n e a9p.San
hcY No
❑ CUOId r, e,byl rash dy �. .ICT,_ =-3ST .. FIRESPRINK ENERGY T-24
Z'Z � 'Gnij�e d copy s Ided.:with Int ,city u:p ctwn•dikison.I
O�, "Ip1. ao 3, F'a0^� - Io g �• s,.•- MISC.- 'r^>t'- REFER-TO ORD' Y N❑ Y ❑ N❑
jr-N CERFIIFFICATCOFEXEMPfION FROM)WORKERS' PERMIT ISSUANCE, 6.00 FLOODZONE A.L.U.C. i
LU > I COhIPENSATION INSURANCE; PLG.CONFER. UC.NO. PLG.
.I r0-aZ ' -�ITIRS,Section need not be completed if the permit is for one TOTAL Y❑ N❑ v❑ N❑
hundred dollar,($100)or less.)
•I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
l LL not is l54 sef.I hall ,or employ any person In any manners.in to
U become object to the Workers' t Compensin on Laws Califorma.
A wa IT t 1ppfe nt ALTER OR ADO TO MECH. 4.00 BUIL�OING) 0.50 .
} m NOTICE TO AI I LICANI If,after making th' Certificate of fix- I)
F Z nnpti n you should become subject to the Workers Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be decnmd revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE -/Yf
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(Sec. MICROFILM
3097,Civ.C.). H EATI NG UN IT (TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Icenll'y that lhuve read this application anWan the above VENTILATION FAN (SINGLE) 3.00
information E, correct. I agree to comply with,11 ci�yand county PLUMBING
ordinances and state laws refuting to buildingconstruction, and BO -COMP(3H.P.or100,0008.T.U.) 4.00
hcrehy outhorize representatives of this city D enter upon the BAILEILERR-COMP ,Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-nnentioned property for inspection purposes.
• (We) agree tD save, indemnify and keep harp less the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs anJ expanses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence of llm
granting of myermit, MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Sign rc of Applicant/Contractor ate /OO
INSPECTOR COPY