6850 ' APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT 1 DENTI FICATIONPERMIT NUMBER
al ADDRESS HOILUIN
- APPLICATION & PERMIT O
-
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
rO�W�wamNI�S a'B PLAN CHECK VALIDATION
QTYELECTRIC PERMIT FEE. '
1 PHONE �'V�QV
ONTflA T
rvAME Q.�.a1 GAJFjve1�E`L''�4OUTLETS-SWITCHES-RECEP 5.00/1.00
�'llc.No LIGHTING FIXTURES 5.00/1.00
ADDRESsroR's. PPLIANCES-RESIDENTIAL 4.00
03/9 /"!'6Kn4Z vilial/$ PHONEaK3-y0S_b PANELS .5.00
DATE OF APPLICATION
ORCHrtECT - SIGNS' 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.No. SIGNS TRANS. - 3.00
ARCH.OR
A OOREss ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00 Jn APPLICANT'S
AOOR,as `�>�' '<., MOTORS SEE FEE SCH.1aSERVICE CHANGE •10.00oA LICENSED CONTRACTORS DECLARATION ID �Ihemby al om mat I am licensed under provisions of Chapter 9 IS ANCEDAT% fC romancing with Section 7000)of Division 3 of the Business amt hoG. 1 v CT. PLG. MECH.Professions Codc;andmy license is in full force and effect.
Zo z v`A,.p License Class Lie.Number
Dote Contractor
OB' I ING PERMIT
¢ w a OWNER-BUILDGR DECLARATION City u
is MISC.- REFER TO ORD INFORMATION
w ; y I hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
u O ¢ Law for9he following reason.(Sec.7031.5,11minessand Prafessinns 6.00
- PERMIT ISSUANCE
Code:Any city or rounfy which requires a panni[[o construct,alter,
¢ ¢o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR:' LIC.NO. ELEC.
¢ requires the applicant for such permit to file a signed statement that TOTAL
¢ w m he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
F z ¢
Law(Chapter 9(commencing with Section 7000)of Division 3 ofllte. '
4 o Business and Professions Code)or that he is exempt therefrom and QTY. - PLUMBING PERMIT FEE
a I-'o the basis for the alleged exam pt ion.An y violat ion o L Section 7031.5 STORIES .TYPE`DN$TR. '
aimby any applicant l'or a permit subjects the applicant to a civil penalty, ALTER-DRAIN (EA.) 4.00
of not more than five hundred dollars($5000.): `
❑ I,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(Sc,. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CONO. 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•. o.PT.PLooR AREA TOTALACREAGE
himself,or through his own employees,provided that such improve-
ments are'not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- .)
builder will have the burden of proving that he did not build or im- GAS-EA:SYSTEM-OVER 4(EA.) 1.00 - ILDING u
prove for purpose of sale.). ' „ RES IND CON' PR .,he,
❑ I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 20.00 ❑ El11 11 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 properly who huilds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec..,B.&P.C.for this WATER HEATER W/VENT
reason4.00
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK17R.S'COMPENSATION DECLARATION' WATER TREATING EQUIP. 4.00 _
I hereby affirm that 1 have a certificate ofconsent to self-Insure, -
acertic
ficate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE N0.
Or S ce"ruof(Se
ro .3800,Lab CJ.
Policy No. Company
❑ Cetifie co yis hereby bis REFER TO ORD. FIRE SPRINK ENERGY T-24
ifi 's f wit th action division. Y❑ N[3 Y ❑ N❑
H p pelican MISC.- '
tD '"RTIFICATEOF EXEMPTION FROM WORKERS' - PERMIT ISSUANCE 6.00 FLOODZONE A.L.U.6f
LU -5 COMPENSATION INSURANCE PLG.CONTR._ LIC.NO. PLG.
M) (This section need not be completed if the permit is for one TOTAL V[:] N❑ V [JNE]Z. hundred dollars($100)or less.)
U O 1 certify that in Ibe performance of the work for which this per- 'QTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL F mit is issued,1 shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California. �j
w Date-ApplicantBUILDING //(l
} talo NOTICE TO APPLICANT: If,after making this Certificate of lix- ALTER OR ADD TO MECH. 4.00
F. Z_ emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK uV
provisions of the Labor Code, you must forthwith comply with -
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,Oo0QF.M.) 3.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0930C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a Construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Cm.C). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that l haveread this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct.I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.MLL) 4.00
.hereby authorize representatives of this city to enter upon the.
above-mentioned property for inspection purposes. R BOILER-COMP(Over t00,000BTU1$EFEE$CH. MECHANICAL
(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
may b any way accrue against City in consequence of the
gran this L MECH.CONT. LIC.NO. - MECH.
// 4 TOTAL TOTAL
Sig rare o App c nl/ tractor Dates
OFFICE COPY