7111 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LD ING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT 7111
ADDRESS
Oe I n BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
OwNER'S PLAN CHECK VALIDATION
NAME DTV. ELECTRIC PERMIT FEE
J. orvE r
CONTRACTORS
,
.AM EC, OUTLETS-SWITCHES-RECEP 5.00/1.00
1 ^ Lc.No. / LIGHTING FIXTURES 5.00/1.00
ADDRESS
AS PPLIANCES-RESIDENTIAL 4.00
ADDRES
PHONE i
Ofl PANELS 5.00 DATE Or APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00 '
ARCHE OR ENG. SPECIALCIRC IT 5,00 PERMIT VALIDATION
ZIP fTEMP.METER OR POLE INS. 15.00
Ais
ADDDRESSDGESS MOTORS SEE FEE SCH.
'
SERVICE CHANGE 10.00
'00 LICENSED CONTRACTORS DECLARATION /
a o u I hereby affirm that 1 an,licensed under provisions of Chapter 9 r/'o/L Oe L /4�G 1 ISSUANCE DATE
or rc "' (convnmming with Section 7000)of Division 3 of the Business and
4 n BLDG. ELECT. PLG. MECH.
0 ve Z License one Cudc,and Ilcaisc is in full force and cf(Sd
0 o m - License Cl s Lia Nwnbe - ❑ ❑
o w F w Dam-/_�[ p>> Contragoy�//A/�
x EL BUILDING PERMIT
Ic a 4 OWNER-RUILDER DECLA A I g�nN
A a=eJ \.'
MISC.- °' REFER TO ORD INFORMATION
wS r 1 chy ufOrm that I am exempt from the Contractor's License
I u.O j Law he following reason.(See 7031.5,Ilusiness and Professions PERMIT ISSUANCE 6.00 VALUATION $/FT.
CodAn -ily or county which requires a permit to construct.alter,
La ¢ o inme,de lish,or repair any structure,prior 10 its issuance,also ELEC.CONTR. LIC.NO. ELEC. �� // 006
- DLL requs the up cant for such permit to file a signed statement that TOTAL PERMIT TO
n w m he iicensed pa ant to the provisions of the Contractor's License
i>
Law(Chapter 9 Hot coring with Section 70001of Division 3 ofthe r-/ y DSL
- 4 Busiss and 1'rolennio Code)or that he is exennpt thercfmm and CITY. PLUMBING PERMIT FEE s.f W� 'ct AJC
¢ rpo the s'is lisr the alleged cmption.Any viDlation of Section 7011.5 STORIES TYPE CONSTR.
a3 �' by aapplicant fora pert lshnjectsthc applicant toacivil penalty ALTER-DRAIN -WATER (EA.) 4.00
^
of nmom Ulan Civc hundn Dollars(55001.): flvnl7 T�
❑ I,as owner of the prop ty,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
theiole cmnpensatipn,will d he work,and the structure rs not
inteed or offered for sale (Sct. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
CodThe Contractor's License La does not apply to an ownerofproty who builds or improves the on,and who does such work FIXTURES-PER TRAP 4.00 So.FT FLOOR AREA TOTAL ACREAGE
himf or through his own employees, ovided that such improve-
menare not intended orolfiend for sale 1',however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or irovement is sold within one year of Unction, the owner- GA$-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING uSE
builr will have the burden of proving that •did not build or im-
pmvforpurposeofsale.). INDUSTRIAL WASTE INTER. 20.00REs wD coN PR ower
❑ I,as owner of the property,am exclusive contracting with ❑ ❑ ❑ ❑ ❑liced contractors in conorost the project(Se 7044,Ilusiness LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
Sod ofessions Code:The Cont rod nr',License La oes not Imply
to aowner of property who builds or improves the on,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
concts 1'or such projects with a contmchms)licensed eluant to
the ntractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.❑ I.Givscmptlmdcr See. ,B.&P.C. b,this WATER HEATER W/VENT 4,00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK HRS'COMPISNSA'FION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Injur nce,or a certifi•d
cops'thereo(ISec.3800,Lah.C.l�.���� Gf l�l�,l F�ILI r-4 L L_ O
Policy Nu. COmPanyl IC.--��f.a__, / !'�
o ❑ milted copy ix hereby furnished. FIRE SPRINK ENERGY T 24
Z Z Lf Cenir'j�d copy Nled with� 'ity inspection division. -
F- O Applicant 1 -.r r e�c�l S MISC.- - REFER TO ORD. Y ❑, N❑ Y ❑ N❑
N PERMIT • SUANCE 6.00 0`t. FLOOD ZONE A.L.U.c.
LU :IikT'IFICATIi OFI;k MOTION FROM WORKERS'
W �_ COMPIiNSAT10N INSURANCE PLG.CONTR. LIC.NO. PLG,
0- O fhht, `x" need not be Completed if the permit is for one TOTAL -4 J Y❑ N❑ Y ❑ N❑
Z hundred dollars 0)orless.I
U O 1 certify that in 1� rlonnance of the work forwhich this per- FEE SUMMARY
I shill note do un rxon in.In manner so us to OTY. MECHANICAL PERMIT FEE
LL F It is issued. Y Y pu Y -
Uw bewmesunjecl to the Worker'S,mpcnsutlonLawsoCCalifornia.-
CL Date Applicant \ ALTER OR ADDITO MECH. 4.00 BUILDING
} W NO"I'ICIi'I'O APPLICANT': 11;alter Ing this Certifiwie of fix- s�
cmption,you should become subject to the W Is Compensation APPLIANCE 4.00 (N PLAN CHECK '
provisions of the Labor Code, you mond for th comply with r FEE
U such provisions or this permit shall he deemed revok AIR HANDLING UNIT(TO 10=r-F.M.) 3.00
CONS'I'RUC'I'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 5.00 SEISMIC FEE 7-7
1 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.L HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lenders None 1�1 ['�I�J C HEATING UN IT 100,000 B.T.U.)7.50 �0
I ldcrs Address ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct 1 agree to comply with all city and county ;PLUMBING
ordinances and state laws relating to building construction, and BOILER-OOA�(3.H,.P.or 100,000 B.T.U.) 4.00 •�
hereby audhodze representatives of this city (o enter upon the BOILER-COMP IOver 100.000 BTUI SEE FEE SCH. MECHANICAL /J B-eJ
above mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD, s
Cupertino against liabilities,judgments, costs and expenses which Jqj CONST.TAX
may n at way ac c against said City in Consequence of the PERMIT ISSUANCE 3.00 �.
gray ng f IIs nn MECH.CONT. LIC.NO. MECH.
�i I 11p, PI TOTAL �Je,�j TOTAL .27
Sig aluure pplicant/Contractor ale / /�U
INSPECTOR COPY