3812 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI. POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION' 'I - PE MIT NUMBER
mmLDING APPLICATION & PERMIT 381
ADDREss BUILDING-ELECTRICAL-PLUMBING-MECHANICAL r,1
0HER'S 7p�. AN CRECK VA TION
NAME 7' QTY. ELECTRIC PERMIT FEE
Ip,
I. PRONE - 7v7z -
C
nMt ACTO
ryG.?btJ
` UTLETS.-SWITCHES-RECEP 5.00/1.00 � U5 � 19 .
uc.NO LIGHTING`FIXTURES ' 5.00/1.00 _ .83.
CONTRACTOR'S
ADOREss C rHp/f0/.A.'�/p$ APPLIANCES!
-RESIDENTIAL 4.00 City of -
PRONE ) ', .g PANELS 5.00 _ DATE DF APpuC��Pertlno .
OR,
RCNITECT SIGNS' 6.00 PLAN CHECK FEE P.C.NO.
ENGINEE
uc.NO. SIGNS TRANS. � 3.00
ARCH. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT .r 5.00
ZIP EMP.METER OR POLE INS. 15.00 �y
APPLICANTS MOTORS SEE FEE SCH.
AOOR S
SERVICE CHANGE - 10.00
00 LICENSED CONTRACTORS DI:CLARATION/�,�09
¢ vu I herchy uff..R that 1 am licensed under provisions of Chapter 9 r ISSUANCE DATE
yz w (commencin with Section 7000)of Divlslon 3 of the Business mud
4 H g - BLDG. ELECT. - PL MECH.
r o z I'rt'essiuns Cody`�aod�nY icense is in 11111 fort•' (fe I 7.
O i H o License Class-[ -- Lia Numhe ❑ ❑ - ❑
F Lit: J
Doc ConRuetor
a m g
¢ a a
OWNER-B UILDIiR DIiC1.ANA1'ION BUILDING P RMIT
A o e- U INFORMATION
3
X I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
I m - VALUATION $/FT.
� LLNa Law forthefollowingreywhichrequirsa persinessand Professions pERMI715SUANCE 6.00
Code:Any c of sh coumy it any requires p Hort to construct,
uance,alter,
�s ELEC.CONTR. LIC.NO.
Q Er improve,he applicant for such
h y permit
t to
a sign its issuance,also TE LEC.
G u requires the applicant for such Permit In file a signed statement that .TOTAL PERMIT TO
Er
$ m he is licensed 9(copursuant to the provisions of the Contractor's License -
•- H 2 s
Law(ChapterProfessions
Codeng with Section is 00)exempt therefrom
of the /
a Business and he alleged a empt or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE ✓
E x a
X 1-$ the basis for the alleged exemption.Any applicant
oto action malty STORIES- 'TYPE CONSTR.
i ; ,. by any applicant fora hundred
subjects llmapplicunt toacivil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundmd A011ars($$DD).)' - '•' '..,
❑ I,as owner of the property,or my cnhployces with wages as -__7BACK FLOW PROTECT. DEVICE 2.00 - OBC.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 PEI
Code:The Contractor's License Law does not apply to an owner of
property who builds 0r improves thereon,and who does such work FIXTURES-PER TRAP4:00 p(/ SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
ments are not intended oroffered for sale.IL however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00 ,
or improvement is sold within one year of.complelion,the owner- GAS EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
•builder v/,11 have the burden of proving tllat he did not build or im- R 5 IND CON PB DhM1ar
provefo purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑
❑ 1 as owner of the property,am exclusively contracting with El El
license contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and P oNssions Code:The Contractor's License Law does not apply -
10' owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 ,
eo true is forsuch projects with a eoutrmtorls)•licensed Pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
c Contractor's License Law.
❑ Imo cxcnpt under Sec. ,li.&P.C.for this WATER HEATER W/VENT 4.00 •(�
Heavoll
Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPIENSATION DECLARATION WATER TREATING EQUIP. 4.00 -
I herchy affirm that I have a cerlificate ofconsenl to self-insure, - ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy Ihereof(Sec.3800,Lab.CJ.
Policy No. Company
0 ❑ Certified co)y is herchy famished. FIRE BPRINK ENERGY T-24
_z Z ❑ CeNific p is 1 with the city 'nspec`y- _ fn Ji°IP own. MISC.- REFER TO ORD. � 0 o
Q Applicant �.d�sfFF v .N V N
CC I PERMIT ISSUANCE 6. //
K - CIiRTIFICA MPENEAl]ON IN PROM WORKERS' (O FLOOD ZONE A.Lu.C.
W > COMPENSATION INSURANCE P CONTR. • LIC.NO., p
L Cl t'fhis section need not he completed if the Permit is for one �. T AL v❑ r,N❑ Y ❑ N❑
Z hundreA Aollnrs lS100)or le'ss.l -
U O 1 certify that in the performance of the work forwhich This per- QTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL H Rol is issued,I shall not employ any person in any munner so as to ,
O W become subject to the Workers'Compensation Laws of California.
Date � A licaut BUILDING
Q, pp ALTER OR ADD TO MECH. 4.00 '
} W NOTICE TO APPLICANT: If,aftermaking this Cerlificate of Ex-
F" Z emption,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 provisionsor this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=1C.EM.) 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,Civ.C.). - H EATING UN IT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 -
Lender's Address ELECTRIC
I C
I'cerlify that l have read this application and stale that the above VENTICATION FAN (SINGLE) 3.00
information is correct. I agree to comply,with all city aiid'coimtyPLUMBING �,.
ordinances and state laws relating r,0 building construction, and BOILER-COMP.(3 H.P.or 100,000 B.T.U.) 4.00
hereby mllturire representatives of this city to cuter upon'the'
above-mentioned property for inspection purposes. BOILER-COMP I0verp00,000 BTU)SEE EEE SCH. MECHANICAL
1
(We) agree to save, indemnify and keep harmless theCity of Misc.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expensnses"which PERMIT ISSUANCE . 3.00 CONST.TAX -
may in any way accrue against said Cily in consequence_ of the
gmnf o his permit. MECH.CONT. LIC.NO. MECH.
- - TOTAL TOTAL X/'J syr
ignat o pplicant/Contractor aic
• OFFICCOPY '