C 6272 APPLICANT TO FILL IN INFOR TION WITHIN RED LINES - USE B*POINT,PtN ONLY-
, BUILDINGPROJECTIDENTIFICATI - PER Ir NUMBER
BDILDIND - [.e7 APPLICATION &'PERMIT -
gOOR"s .6 2 7 2
- •/� . /� D � BUILDING=ELECTRICAL-PLUMBING.-MECHANICAL rV1G f G
W EP V '� .'w V PLAN CHECKYADATION.ELECRICrP'dERMEEIf /Q/L/NANTRgcroRs. OUTLETSSWITCHES-RECEP 5.00/100 /
NgM"E" •�,
L(J �s� sec.rvo.3 LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S APPLIANCES;RESIDENTIAL 4.00
-
7F45
-
�PHOIN PANELS 5.00 DATE OF APPLICATION
ARCHITECT '• SIGNS'• 6.00 ' PLAN CHECK FEE P.C.NO.
ON
pt.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. . o . PERMIT VALIDATION
'ADDRESS - , SPECIALCIRCUIT ' '5.00
ZIP TEMP.METER OR POLE INS. 15.00 P
APPLICANTS MOTORS SEE FEE SCH. .---�
ADDRESS y,
- SERVICE CHANGE 10.00 B O '� y -
'.02 LICENSED CONTRACTORS DECLARATION- G ��0�
a u v I hereby affirm that I am licensed muh,provisionsof Chapter 9 ATE
,Hn w (commencing with Section 7000)of Division 3 of the Business and _8013. PLG. MECH.
H.m z Professions Code nd-my license is io full for • cf
License lass Lic.Number �'
4 w Date�Contractor ..
¢ y - i." `BU ILDING PERMIT
¢ ¢w¢ OWNF;R-BUILDER DECLA ION _ -
n'
" MISC.- REFER TO ORD . �N FORMATiION
w ;u y I hereby affirm that I am exempt from the Contractor's License
H ic 04 Law for the following reasom(Sec.7031.5,Businessand Professions PERMIT ISSUANCE, 6.00 VALUATION §/FT.
vi Code:Any cityorcounty which requires a permit In construct,alter,
//-•f M.�f
EE> improve, or repair any structure,prior toils,issuance,also . L1
ELEC.CONTE. 71 ELEC.
- o¢ requires the applicant for such permit to file a signed statement that TOTAL
A w m ic he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
i
Law(Chapter 9(commencing with Section 7000)of Division 3 of the r 'a: r8 ,�
4 i o Bus mess a W I'rofcssons Code)or that he is exempt therefrom and STV; , > PLUMBINPERMIIT ry4� x FEE
¢1- the basis for the alleged exemption Any violation of Section 70315 y. < .�i. k .:Y• STORIES TYPE CO TR'
d ; - by any applicant JOE Ir re dollars the applicannoucivilpenalty ALTER-DRAIN&VENT-WATER (EA.) 4.00 S�
of net more than five hundred dollars(my xm):'.'x- - i v �
❑ Las owner at the property.or my employees rich-wages as BACK FLOW.PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
(heir sole compensation,will(S the work,andBusiness
the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 /
code:pety*fire h o builde r License law docs not apply loan owner of
property who builds or improves employees,
pr and who does such work FIXTURES-PER TRAP 4.00 sa Fr.FLooR AREA TOTALACREAGE
himself re of rote his own mered for Sale.provided that such improve- -
misndedor withinroneyeaoIcompletion(lie the oiling GAS-EA.SYSTEM-I1NC.40UTLETS 4,00
or improvement have
is sob within one year of the did completion,the arae"- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or int- .purpose - INDUSTRIAL WASTE INTER. 20,00 fles IND CON PB Other
0 1,d as owner of the property,he exclusively, 7044,Bu with ❑ ❑ ❑. ❑ . ❑
licensed contractors to construct the project lSec. 7044,Business ' LAWN SPRINKLERS-1 INC5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor'.%License Law does not apply - �- 3 ']
to un owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 - -
cont"Cis far such projects will,a contratmr(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO. PARCEL NO.
❑ I ani exemptunder Sec. ,B.&P.C.I'or this WATER HEATER W/VENT 4.00 �0�0
Reason
Owner Dale _ WATER SYSTEM - 4.00 ACC-DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION, WATER TREATING EQUIP. 4.W -
I hereby affirm Iset I have a certificate of nn..ent to self-insure, - ZONING
or a certificate of Workers'Compensation Insurance,or a tertid'ied ENG.SITE NO.
copy thercof(Sce.3800,Lab.C.) L!� �As TSL
Policy No. _Company s
Q ID CL't is copy is here famished. FIRE SPRINK ENERGY T-24
Z Z O Cer ifie py, s f •d ith the c'1 inspection division. MISC.- REFER TO ORD.
O APPlican - - V❑ N❑ Y ❑ N❑
r va 'PERMIT ISSUANCE 6.00
- CP IFICA'1'E P J iMI'TION PROMWORKIiRS• FLOOD ZONE A.L.u.c.
L COM I: TION INSURANCE - PLG.CONTR, LIC.NO. PLG,
d O (Ilii,, section need not be completed if the permit is for one TOTAL Y'❑ N❑ Y❑ N❑
Z Hundred dollars(SI00)or less.)
U O I certify that in the performance of the work for which this pe 7QT4Y.u. MECHANICAL PERMIT v"W EE °A `• F,EE SUMMARY
LL F mit Is issucA,I shall not employ any person in any manner so rc In n F,v ,. e y...,v3,,. .
U become subject to the Workers Compensation Laws ofCal - • • -
0 a
Date-Applicant ALTER OR ADD TO MECH.y 4,00 BUILDING
} N NOTICE '10 AITLICANT: IL.xfter n"king this Certificate of fix-
2 emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwithcomplywith FEE
U such provisions or this permit shall be deemed revoked. . AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION L17NDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construclimi lending agency for EXHAUST'HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.Cd. - . HEATING UNIT(TO 100,ODO B.T.U.) 4.00
- - -Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. 1 agree to comply with all city and county - PLUMBING
ordinances and state Tawe relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of This city to enter up.. the BOILER-COMP (Over 100,000BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.' _
(We) agree to save, indemnity and keep harmless the City of MISC.'- REFER TO ORD. CONST.TAX
.
Cupertino against liabilities,judgments, casts and expenses which
To ony way ucc against said City in cense uence f the PERMIT ISSUANCE 3.00 a T'�
g nliigof chi Penn'. MECH.CONT. - LIC.NO. MECH. ", •,,,
TOTAL '/;/� •3
TOTAL'kx d /c
SI I c of Ap mai .ontruc or Datc
• OFF,ICECOPY -