4870 APPLICANT TO FILL IN INFORMATIO WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERM TNUMBER
EDLDINs APPLICATION & PERMIT /�
D BUILDING - ELECTRICAL-PLUMBING -MECHANICA 4QUZ0
OWNER'S PLAN CHECK VALIDATION
NAME) QTY. ELECTRIC PERMIT FEE
�/7 //�/yc) PHONE' PAID
CONTRACTORS
rA`ME tsS
OUTLETS-SWITCHES-RECEP 5.00/1.00S/ uc.No 1JI LIGHTING FIXTURES 5.00/1.0JAAl 1I �L3�CDG PPLIANCES-RESIDENTIAL 4.00 hi1V 11COr ' (/f� ONE Ar-4 G'7 PANELS 5.00 DIKJ.QFtP4PMgtWrt1j
ARCHITECT _ SIGNS 6•.DD PLANPEE-] .0.N0.
OR
ENGINEER
LIC.NO. SIGNSTRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5,00 NPERMIT IDATION
zIP EMP.METER OR POLE INS. 15.00
APPLICANTS' MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.0000o LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chatter - E DATE
y¢ (commencing with Section]000)of Division 3 of the Business o B DG ELEC PLG. MECH.
r y i Professions Code, IT n icense'is in full force a eCC 1 ❑ ❑ ❑
z o m - License Class - Lic.Number �"7 -
o N t ta Date Y !. f-K_Colnracmr u
¢ Y s ` •� BUILDING PERMIT
¢ ¢ a 'OWNER-N UILUI>R DECLARATION'
o d " tContractor', MISC.- EFER TO ORD INFORMATION
w 3 LL of I hereby affirm that I um exempt Irum the Licen a VALUATION
H .. oa Law for the following reason.(Sec.7031.5,Business and Professio s PERMIT ISSUANCE 6.00 $/FT.
yv+ Code:Any city'or county which requiresa permit t COOStruct,all r. -
2 ¢ ¢ 2 improve,demolish,or repair any structure,prior to its issuance,al c ELEC.CONTE. LIC.NO. ELEC. A
-O¢ requires the applicant for such permit to file a signed statement th t TOTAL PERMIT TO
he is licensed pursuant to time provisions of the Contractors Licen a
Hzr
Law I(Chapter 9(commencing with Section 7000)of Division 3 of Ie
x o Business and Professions Code?or that he is exempt therefrom a d OT;' PLUMBING PERMIT FEE
¢ r m
the basis for the alleged exemption.Any violation of Section 7031 5 TYPE ONSTR
u3 � by any applicant for a permit subjects the applicant moa civil penal ,gLTER-DRAIN& VENT-WATER (EA.14.00
of not mom than five hundred Aollars(5500).):
O I,as owner of the property,or my'inPloycce,with wanes as BACK FLOW PROTECT. DEVICE 2.00 occ.GROUP EES.UNITS
their sole compensation,will du the work,and the structure is rt
intended or offered for sale (Sec 7044. Business and Professi s DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contrucmi s License Law docs not apply to on owner C
property who builds or improves thereon,and who does such w rk FIXTURES-PER TRAP 4.00 So,PT FLOOR AREA TOTAL ACREAGE
• himself re through his own employers.provided that such impro e-
rents are through
oroempl employee,,
or provided
haegthebuBA g GAS-EA.SVSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion, the ower GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or -
proveforpurposeol'sale_). INDUSTRIAL WASTE INTER. 20.00 IIID CON PB Drhem
❑ 1,as owner of the property.am exclusive],coalition,w th ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Basin ss LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contracmor's License Law does not all ly
to an owner of property who builds or improves thereon,and ho LAWN SPRINKLERS-OVER 5(EA.) 1.00
-hotrods for e
jrn
p
suchLwith acontmetorts)licensed purism to
the Contrucmi s h projects
Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec.-.BAP.C.for is
WATER HEATER W/VENT 4.00
reosun
Date 0,va" WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK f:RS'COMPENSA'FON DECLARATION WATER TREATING EQUIP. 4.00 _
I hereby affirm that 1 have a cnrtifierte of consent to sell'-ins ne ZONING
or a certificate of Workers'Compensation Insurance,or a certi ied
ENG.SITE NO.
Copy themof(Sce.3800.Lab.C.l. '
Policy No. Company -
O ❑ Femitled copy is hereby furnished FIRE SPRINK ENERGY T 24
Z Z Certified copy is tiled with the city inspection divis in. MISC.- REFER TO ORD.
0 Applicant Y ❑ N❑ I Y ❑ N❑
it CERTIFICATE:OF I KF.MPI'ION'FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
W > CONIPEN'SATION INSURANCE PLG.CONTR. LIC.NO. PLG,
0- 0 1'Flu, section need not be completed if life permit is (for rc TOTAL Y❑ N❑ Y❑ of
hundred dollars(S 100)or lea.)
U O 1 certify that in the performance of the work for which this TY. MECHANICAL PERMIT FEE FEE SUMMARY
er- Q
LL I- mit is issued,I shall not employ any person in any mm�ner sn's m
U become su lett to t e Workers'C nmpcnsati n Law of C' i(onm 9. ,
� w Dat0 z A ' Applicant r-- -e BUILDING
a ALTER OR ADD TO MECH. 4.00
} to NOTICE '1 O AIT (CANT: 11',after making this Cer Cemc of hx-
Z emption,you should become subject to the WmIon, Compens- ion APPLIANCE 4.00 PLAN CHECK
provisions of tie Labor COLIC, You next forthwith comply ith. FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONST RUCTION LENDINCAGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE 1
1 hereby affirm that there is a construction lending agent for EXHAUST HOOD(WITH DUCT) 2.00
the performance of(lm work for which this permit is issued Sec. - MICROFILM
3097.civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)7.50 ELECTRIC.
Lcndur's Addmss
I Certify that I have read this application and slate that the ove' VENTILATION FAN (SINGLE) 3.00
Oleinformation is correct. I agree to comply with all city'and ct my PLUMBING
ordinances and stale laws relating to building construction mid BOILER-COMP I3 H.P.or 100,0006:T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purpows.
(We) agree to save, indemnify and keep hanolces the Ci y of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, Costs and expenses hich CONST.TAX
may in ntry way accrue against said City.in,curee"Remee o'the PERMIT ISSUANCE 3.00
ng of thi permiL G H
MECH.CONT. LINO. MEC .
TOTAL
granti - / TOTAL
Signature of Applicant/Contractor Date
OFF16F COPY