8894 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT ^
ADDRESS i'-' y
.� �/ 5-,2[ I,7 �L BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S �"� PLAN CHECK VALIDATION
"AME ER 1-/ QTY. ELECTRIC PERMIT FEE -
C PNONE
NAAMERACTooL s UTLETS-SWITCHES-RECEP 10.00/1.00
LIc.No. LIGHTING FIXTURES 10.00/1.00
DRRAcroRs
ADDRESS APPLIANCES-RESIDENTIAL 4.00
A
PHONE PANELS 10.00 r DATE OF APPLICATION ✓
ARCHITECTPANELS (OVER 200 AMPI 20,00 PLAN CHECK FEE P.C.NO.
ENGINEE UAA/OA/ IF VY
LIc.No, SIGNS TRANS. - 3.00
ADDRESS ERG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
( L - zlv EMP. METER OR POLE INS. - 20.00
A/iC
"Ale
A:S
ADDRESS
AyQ
DREss
MOTORS SEE FEE SCH. �/
Z 151 F � SERVICE CHANGE 20.00 (
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 Q/�`I'
a is u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w a w (commencing with Section 7000)of Division 3 of the Business and t BLDG. ELECT. PLG. MECH.
r•y z Professions Code,and my license is in full force and effect ❑ ❑ ❑ ❑
z D m - License Class Lic.Number s
O o t ata Dare Contractor
a y f BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
A o a u INFORMATION
X 3 LL N 1 hereby collo that I so exempt 31.5 the Contractor's License MISC.- REFER TO ORD
LL o¢ Law for the following reason.(Sea 7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city or county which requires a permit to construct,alter,
QQ Q p Improve,demolish,or repair any structure,prior t0 its issuance,also ELEG CONTR. LIC.NO. ELEQ �d //f/ •�
a y m¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w he is licensed pursuant to the provisions of the Contractor's License Ti2q,y
' t- Law(Chapter 9(Commencing with Section 7000)of Division 3ofthe s+ �`
iao Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE x `
o: I-m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CON TR.
a ; _ by anyapplieunt for a permit subjectsilre applicant on civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00 1 /
of not more than five hundred dollars(5500).) - -�V. //L
❑ Las owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of ^ J
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE
• himself re of rote his own employees,provided that Baer ingxave. .
hats are through
his or offered yes,ot prove. ided
thathowevs the.building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 B ILDING USE
builder will have the.burden of proving that he did not build or im-
IT rove for purpose ofsale.). INDUSTRIAL WASTE INTER. 3000 RES IND CDN PR Omer
pp 1,as owner of the property,am exclusively contracting with . ® El ❑ ❑
IiCXwd contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code,The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for Such projects with a contractor(i)licensed purinant to
the Contractor's License Law. I SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under See.-,BAP.C.forthis WATER HEATER W/VENT 6.00
reason
XOwner .1 - Dam Thr WATER SYSTEM 5.00
� _'I.'ileo ACC.DATE ACC,FILE NO.
WORK 7R bN DECLARATION WATER TREATING EQUIP. 5.00
I hereby aifnm that 1 have a certificate ofconsent to self-inntm, ZONING
Or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE N0.
Copy rhymer(Ser.3800,Lah.CL
Policy No. Company _
O ❑ CCrL111Cd copy is he by furnished.
FIRE SPRINK ENERGY T24
Z 2 ❑ Certified copy is Filed with the city inspection division.
O_ Applicant MISC.- REFER TO ORD. v ❑ N❑ v ❑ N❑
a CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
LU > COIdPF-NSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
•Q_ Z (This section need not be completed if the permit is for one TOTAL Y❑ N❑ v C] NE]
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE -FEE SUMMARY
LL l- lion is issued,I Shull not employ any person in any manner so as to
U w become subject to the Workers'Compensation Laws of California. BUILDING
d Date Applicant ALTER OR ADD TO MECH. 5.00
} to NOTICE TO APPLICANT: IL after making this Certificate of ISx-
{- ? cmption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of tiro Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deynred revoked. AIR HANDLING UNIT(TO 10=C.F.M,) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IQOOOC.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction landing agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Cie.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name-IFI/ �aA G'(� HEATING UNIT(OVER 100,000 B.T.U.19.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
. information is correct. 1 agree to comply with all City and county PLUMBING
ordinances and stmc laws relating to building construction, ,it BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hemby.autho.ite representatives of this city to corn. upon the BOILER-COMP (Over i00,000BTUISEE FEESCH. MECHANICAL
above mentioned property for inspection purposes.
(We) agree m save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
granting of this permitMECH.CONT. LIC.NO. MECH.
\1 udoi
41 TOTAL TOTAL
'igmRpAC of pidicant/Conmatto Date
INSPECTOR COPY