C5699APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LD ING PROJECT IDENTIFICATION
APPLICATION &PERMIT
jRMIT NUMBER
MEMO
ADDRESS
'
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
5699
OWNER'S
PLAN CHECK VALIDATION
NAM E
OTY. ELECTRIC PERMIT FEE
ANCI orvE
cioBs
NAME
NAME
UTLETS- SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
LIC. No.
DATE OF APPLICATION
CDNTRAcions
ADDRESS _
OOF'o
17
PPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
ARCHITECT
OR
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
NGINEER
LIC. NO.
SIGNS TRANS. 3.00
moo ESS E
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 75.00
-
ZIP
APPLICANT'S_
ADDRESS
,` l-
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSI!D CONTRACTORS DECLARATION
- �.
I hereby.afOnn ilial I am licensed under provisions of Chapter 9,
IcommcnFing with Section 7000) of Division 3 of the Businefs and'.
I'rolessions Co as mylicenseisinfu8fur 3n dfec�O
Lice I `Class Lic. Number
Ua1c �pE Contractor
ISSUANCE DATE
- .. .- - - --_... _- - -
BLDG.
❑
ELECT.
❑
.PLG. MECH.
❑ ❑
BUILDING PERMIT
INFORMATION
OWthatI am examLDER t fromDECLRucCoroAHON
I con exempt Coln thu Contactors License
hereby affirm following
Lawfarthuity oningrcason.(See.uiresa permit Business and Professions
Code:
e,demysh countywhiny structurep riort oconsuance, also
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions ol'tire Contractor's License
V
MISC. - REFER TO ORD
PERMIT ISSUANCE 6.00
VALUATION
sc�..il
1
$/FT.
ELEC. CONTR. LIC, NO�
ELEC.
TOTAL
PERMIT TO
OTY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000) of Division J of the
Business and Professions Code) or that hu is exempt therefrom and
p
'e.. R '
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
by any appheant I.. a permit subjects tireaPPlicam m a civil penalty
of not more than five hundred dollars (8500).):
e )oo�
ALTER -DRAIN & VENT -WATER (EA.)4.00
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon. and who does such work
himself or through his own employees, provided that such improve-
mentsarenotintendedorofferedforsale. If, however, the building
FIXTURES - PER TRAP 4.00
SO. PT. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM -1INC. 4 OUTLETS 4.00
lir improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
prove for purpose of sale).
13I, as owner ol'the property, um exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 1.00
BUILDING U$E -.
RES IND CON PB Doe,
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 4000
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code :'I'he Contractor's License Law does not apply
to an owner of property who builds or improves (hereon. and who
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
LAWN -SPRINKLERS - OV ER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
comlmc Ls for such projects with a contrxetons) licensed pursuant to
the Contractors License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ lam exempt under Sec. ,BAP.C. for this
reason
WATER HEATER W/VENT 4.00
Owner Date
WATER SYSTEM 4.00
ACGDATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
WORK FRS'COMPENSA'I']ON DECLARA'f ION
I hereby affirm that I have a cerGlicalu of consent towil'-insure,
or a certificale of Workers' Compensation Insurance, or a certified
ZONING,
ENG. SITE NO.
'Copy the, I;ISem. 800 V1�ab.C.I ei-
I'ohcy No q�fkfSo srr%('-
❑ Ceoified copy is hc((eby furnished.
ILL,
rti5ed copy tiled with he it inspection division.
Applicant Tics o/w �1 n-sn )
FIRESPRINK
Y❑ N❑
ENERGY T-24
Y❑ N❑
MISC.- REFER TO ORD.
CI'RTIF.ICA'1'1:OF fix FMPPION PROM WORKFRS'
PERMIT ISSUANCE 6.00
FLOODZONE
A.L.U.C.
PLG. CONTR. LIC. NO.
PLG.
TOTAL
COMI'ISNSA'I'ION INSURANCE
1'flux wvtioR need not be completed it the permit is for orm
Y ❑ N❑
Y ❑ N
hundred dollars IS 100) or las.)
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so as to
CITY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
(�
l JJJ
become subject to the Workers Compensation Laws of California.
Date Applicant
NOTICE 'f0 APPLICAN 1': If, after making this Certificate of Ex.
ALTER OR ADD TO MECH. 4.00
APPLIANCE 4.00
PLAN CHECK
eruption. you should become subject to Die Workers' Compensation
provisions of the Labor Code, you must liuthwi0l comply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10,ODDGF.M.) 3.00
AIR HANDLING UNIT (OVER IQODOC.F.M.) 5.00
SEISMIC FEE
CONSTRDCfION LENDING AGENCY
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.
3097, Cv.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
Lender's Name
Lender's Address
I certify that I have read this application and slate that the above
VENTILATION FAN (SINGLE) 3.00
infoucation is correct. I agree to comply with all city and county
ordinances and stale laws relating to building Construction, and
PLUMBING
BOILER-COMP(3 H.P. Or 100,000 B.T.U.) 4.00
BOILER -COMP (Ove, 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property 1'or inspection purposes.
MISC. - REFER TO ORD.
(We) agree to Save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs .".expenses which
may in any way accrue against said City in Consequence of the
CONST. TAX
PERMIT ISSUANCE -( 3.00
granting Of this permit.
MECH. CONT. LIC. NO:
MECH..
�' /,r-
of
.
TOTAL
'
TOTAL
O
Sign Appl i cant/Contractor Dote
INSPECTOR COPY