6183 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION PERMIT NUMBER
BGILDING - APPLICATION & PERMIT �� ��
ADDRESS
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S b PLAN CHECK VALIDATION
NAME / OTY. ELECTRIC PERMIT FEE
• G4f
CONTRACTORS
UTLETS-SWITCHES-RECEP 5.00/11-0qnS
NAME
LIGHTING FIXTURES 5.00/1.00 10,e -
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS �-
C PHONEPANELS 5.00 DATE OF APPLICATION
ARCHITECT -SIGNS 6,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.no. SIGNS TRANS. 3.00
ARCH,OR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS g MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00 , Q/�/�`7
woo LICENSED CONTRACTORS DECLARATION
<v U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
,HA a w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F N z 1'rol'essions Code cid my license is in full far' and IeCL. OCT 1984
❑ ❑ ❑
zo - License Class- _D Lit.Number / -T�
< y Umc Contractor
w a OWNIR-BUILDER DECLARATION BUILDING PERMIT INFORMATION
O R F D INFORMATION .
w3 LL t- 1 hereby alDnn that 1 3...exempt from be Contractor's License MISC,- // - VALUATION J S/FT.
Fuo< Lnw for tire following reason(Sec.7031,5.I3usinessand Prafesuons PERMIT ISSUANCE 6.00 p
Coder Any city or county which requires a permit to constnlct,alteq
QQ Q 2 Improve,demolish.or repair any structure,prior to Its Issuance,a),(, ELEC.CONTR. LIC.NO. ELEC. �f O
O IZ requires the applicant for such permit to Fite a signed statement that TOTAL D�- PERMIT TO
La se u. he is licensed pursumn to the provisions of the Contractor's Licenm
El-
Law
(Chapter9(cummencing with Section 7000)of Division 3 of the
CG
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE /
r c the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n ; w by any applicant lir a permit subjects theapplicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
of not more than five hundred dollars(5500).):
o 1,as owner of the propcny.or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole cunpensation,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
pnrperry who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 50,FT,FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
mentsare not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of prising that he did not build or int' RES IND CON PB Omer
prove for Purpose oleate.). INDUSTRIALWASTE INTER. 20.00 ❑ ❑ 0 ❑ ❑
❑ 1,as owner of the property,Con exclusively contracting with
licensed contractors to construct the project(See.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:'I'lie Contractors License Law does not apply
to art owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contmclots)licensed pursuant Io SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the Contractor's License Law,
C, I wn cxcmpt under Sce, ' .B.&P.C.lot this WATER HEATER W/V ENT 4.00
rcasln
Owner Dale WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate ofconsen(to sell-insure.
ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
Copy(hereof(Set.3800.LaIrC.I
pollicY . Conpany, ic
O W�tcrlilied .
-f"IC
copy is hereby furnished FIRE SPRINK ENERGY T 24
Z Z ❑ Certified spy fled ith thp^[yy inspection division. misc.- REFER TO ORD. Y E] N� Y E] N[]
I"' O •Applicant �I LLF' -
CC y CER'f1171CA'1'1.OF EXEMPTION PROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.ILC.
L >_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y q� .v N�
d O (this section need not be completed if the permit is for one TOTAL
Z hundred dollars IS 100)or less.) -
V O 1 certh,that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL N mit is issued,I shall not employ any person in any manner so as to
O w become subject to the Workers'Compensation Laws of California. BUILDING
Dade AvplicAm ALTER OR ADD TO MECH. 4.00
} y NOTICE TO APPLICANT: IL after making this Certificate of Fix-
enOltion,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 he deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION Ll'NDING AGENCY AIR HANDLING UNIT(OVER 10=11C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that th
ere 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.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender,Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certity'that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
• information is correct.I agree to comply with all city and county BOILER-CIXv1P(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby uutoriee representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
abuve-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgmenls, Costs and expenses which CONST.TAX
may in any way accrue agar md'City in consequence of the PERMIT ISSUANCE 3.00 is
grant'ng off er iL MECH.CONT. LIC.NO. MECH.
4F�9?/SX TOTAL TOTAL,
Signature of A licanl/Contractor ate
OFFICE COPY