4846 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI_ POINT PEN ONLY
' BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
A DoUSs/oa O �1�i✓ E a APPLICATION & PERMIT 4846
ZO�G5- L cIZ�INE BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME 3 Z�9Z PRDN QTY. ELECTRIC PERMIT FEE
: Cc
NAME ATORS OUTLETS-SWITCHES-RECEP 5.00/1.00
N //
iC �NG LIC.No�(O LIGHTING FIXTURES 5.00/1.00
ADDNTEACTOH's RESS APPLIANCES-RESIDENTIAL 4.00
DLJ IVr VRONE7-�� /��/C PANELS 5.00 DATE OF APPLICATI`NI I
ARCHITECT SIGNS B4O0 PLAN-CHECK P.C•N0,
OR n5 `/l, t
ENGINEER !/ . B p
JL tic.No`6o SIGNS TRANS. 3.00 H
ADD . /SI L.O SPECIALCIRCUIT 5.00 PERMIT vnuoenoN
ADDRESS
.ip
RCHE ss ENG// ,/
1-747onP `/j0 EMP.METER OR POLE INS. .15.00 C�*�Of
APPLICANT' MOTORS SEE FEE SCR. CU�B�fIpO
ADD�R7ESS /
/� /l//���/J- SERVICE CHANGE 10.00
wo o LICENSED CON'TRACIORS DIiCLARATION
a u u I hermby affinn tlmt I not licensed under provisions of Chapter 9 ISSU"NCE OAti6
H A A (cont mencit g with Section 7000)of Division 3 of the Business and BLDG' ELS GT. L EC 1
r o z Professions Cgg{{le and myy liceppux is in full fort• t f t A
zo - License Cln2il IC1 {�Eic.Number y�7-/�/ - ❑ LJ 3 /
ti w D'etc Contreeto
st Or ..»»
a c F y � DE - Y' - ...4n ' ,�f' f. _9U{LDIf.JG PERMIT �i•
¢ ¢ w a OWNER-BUILDIiR DF.CLA RATION s INFORMATION
aoa ° MISC.- REFER TO ORD -
wLL H 1 hereby affirm ing I am exernpi from the Contractor's fisomnc
F u• o¢ Taw for the following rcason.(Scc.7031.5.Busin<ssand Professions PERMIT ISSUANCE 600 VALUATION SIFT.
Code:Any city or county which requiresa permit tuconstruct.alter.
¢ ¢ a p improve,demolish,or repair any structure.Prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
so
o ¢ ¢quires the applicant for such permit to file a signed statement that TOTAL PER TO
A w m" he.is licensed pursuant to the provisions of'tire Contractors License
� zQ Law(Gh.,Icr9IcDlnmeneingwilll Seaion4000)nf Division 3 of the
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ o the basis for Rte alleged exemption.Any violation of Section 7031.5 1 STORIES TYPECONSTR.
a _ by any applicant for a permit subjects the applicant ton civil Penalty ALTER-DRAIN & VENT-WATER (EA.) 4.00
01'nut mnrc than five hundred dollars(S500).):
❑ 1,as owner of rhe property,or by 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 dues such work FIXTURES-PER TRAP 4.00 So.rT.rLOOR AREA T70TAL ACREAGE
himself or through his own amp lay acs,provided that such imp rnva-
• mentsare lmtintended oroffered l'or sale.If,however,the building GAS-EA.SYSTEM-11NC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
pmvelo,parpowofxwe.l. INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB othnr
Cl 1.as owner of the property'.am exclusivelY'contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project ISec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Prolissions Code T'he Contractor's License Law docs not apply
to an owner of property who builds of improves thereon,and who LAWN SPRINKLERS-OVER 5IEA.) 1.00
contracts for such projects with it contractors)licensed punuaut to
the Contractors l.icensc Lar,v SEWER-SANITARY-STORM EA.200ft/8.00 TRACT No. PARCEL No.
❑ tom exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK Ii RS'COMPENSYNON DECLARATION WATER TREATING EQUIP. 4.00
1 bereby uff,,R that 1 hove a certificate of cnsent to Ulf-insure.
ur a certificate of Workers'Coniponsution Insurance,oor a oroificd ZONING ENG.SITE NO.
copy thereof(See 3800,LAC.).
Folic Nn. Company
-0 artitied copy is IP, famished.d. ENERGY T-24
z.Z Certified copy.isT tiled 'Ili,1,the city inspection division. -
O 'nernl MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
CI;R'I IFICA 11017 EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 v FLOOD ZONE A.L.0 c.
w� o . co5lrr:NSATIONINsuRANCI: PL�cONTR. GNt �� T'TA20 �_ ❑ ❑ ❑ ❑
!This section need not be completed if the penia Ls for one //4��' (� Y N V N
Z hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F nn it is issued. I shall not mmploy any person in:my manner so as to
U hecome subject to the Workcrs'Con.pensmion Laws of Calilortln.
y Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of li.o
F Z^ ennption,you should become subjectit)the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply withFEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00 L
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER LOMC.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 I'or which this permit is issued(Sec. MICROFILM
3097,Civ.C.1. HEATING UNIT(TO 100,000 B.T.U.1 4.00
Lender's Name
Lender's Address HEATI NG UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Ithatc read sa )caion and tatcthotubave VENTILATION FAN (SINGLE)
3.00
information is correct. I agreeto comply ah all city and
3�
rounty PLUMBING v
oNinun«s and state laws relating to building construction, ani BOILER-OOMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby ollic,e represuntatives of this city to enter upon the. BOILER-COMP (Over 100000137WSEE FEESCH.1 MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against Iubilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
uw ny y ecrue again said City -n consequence of the
gent in f I w vacs). / _ ECH.CONT. LIC.NO. MECH. U
�p TOTA�/ O TOTAL
gn pp marl/Contractor )arc /1/•/
r INSP CTOR COPY