5688 APPLICANT TO FILL IN INFOFLMATION WITHIN RED LINES - USE 90L POINT PEN ONLY
„ BUI LDI NG PROJECT I DENTI FIC 1 PERMIT NUMBER
d- BUILDING APPLICATION & PERMIT
ADDRESSC Q Q
/ BUILDING -ELECTRICAL-PLUMBING-MECHANICAL J uV
C NCRS PLAN CHECK VALIDATION
' aAME DTV. ELECTRIC PERMIT FEE
PHONE
DTDRs
NAME UTLETS-SWITCHES-RECEP 5.00/1.00
NAME
LIC NO. LIGHTING FIXTURES 5.00/1.00
ATons
ADDRESS APPLIANCES-RESIDENTIAL 4.00
NTRAC
PHONE PANELS- 5.00 DATE OF APPLICATION
ARCHITECTSIGNS 6,00 PLAN CHECK FEEI.C.NO.
OR
ENGINEER
_1C.NO. SIGNS TRANS. 3.00
ADDDRR'ESS ENC SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00r
APPLICANTS MOTORS SEE FEE SCH. .1
ADDRESS
SERVICE CHANGE 10.00
'00 LICI,NSED CON]RAC DECLARATION
<
an
U I hereby affirm that I con licensed under provisions of Chapter 9 ISSUANCE DATE
G G (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H m rolessions Code and my license is in full force and effect. ❑ ❑ - ,❑ ❑
z Oz m License ClassLie.Number
2H w I Datc Contractor
CE Y 2
K m w ¢ OWNER=P UILUIiR DECLARATION BUILDING PERMIT
INFORMATION
0 0 ° REFER TO ORD
aa, 3 u y I hereby collo that I am exempt from the Contmdor'oLceons MISC.-
u O J Law for the following VALUATION' S/FT.
greas�n.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 6.00
In WCode ro e,dem.or rouNy which regn tan,pe .,1.it,i,,c.cL aaeq
¢ a In improve,demolish,m repair any stnsturu,prior m its issuuna,also ELEC.CONTR. ❑C.NO. ELEC.
- O ¢ requires the applicant for such permit to flu a signed statement that TOTAL PERMIT TO
w " he is licerood pursuant to the provisions of the Contractor's License p�g�` -
O
Law(Chapter mi
r 9(comenchtgwith Section 7000)of Division3afthc � O -V
¢ Business and Professions Cate)or that he is exempt therefrom and OTY. PLUMBING PERMIT
¢ r o the basis for the alleged exemption.Any violation of Section 703 LS TYPE CONSTR.
n ; m by any applicant for a permit subjects me applicant too civil penalty ALTER-DRAIN& VENT-WATER IEA.) 4.00
of not more than Five hundred dollars(55001):
if
❑ I,as owner of the property,or my employs with wags as BACK FLOW PROTECT. DEVICE 2A0 a .GROUP RES.UNITS
their sole compensation,will do the work,and the structure Is not
intended or offered for sal,(Sea 7144, Business and Professvons DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Low does not apply to an owner of
• prulwrty who builds or unprovs.themon,and who dos such work FIXTURES-PER TRAP - 4.00 CO.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees:provided that such improve-
mentsare not intended oroffered for sale.IL however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold,within one year of completion.The owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 eulLDlrvG USE
.builder will have the burden of proving Thm he did rear build or int- RES IND CON PB Omer
prove for puTosa of mlc:).. INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the pnipcRy,an,exclusively contracting will, ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS:1 INC 5 V.B. 5.00 AsSESBOHS PARCEL NO.
and professions Code:The Contractor's Licer ie Law dues not apply
to an owner of property whir builds or improves thereon,and who - LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts fur suets projects with a contraclov s)licensed pursuant To
(be Cnmrador's License w. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCELING.
❑ lam tacngn olid 'uc. ,B.&P.C.for this WATER HEATER.W/VENT 4,00
son
�c. Owner Date WATER SYSTEM 4.00
ACC.DATE ACC.FILE N0.
WORKERS'COMPENSATION DECLARATION- WATER TREATING EQUIP. 4.00
hereby affirm that's haw a cenifcate of crooner to wlf-insure. ZONING
or u certificate of Workcri Compensation Insurance,or a certified ENG.SITE NO.
copy thereof tSec.3800,Lub.C.).
Policy No. Company-
O, ❑ Cti-injedcopyeherehyfumished. _ FIRESPRINK ENERGYT.N
Zi Z ❑ Certified copy is filed with the city inspection division. MISC.- ' REFER TO ORD. YE:] N❑ Y N❑
O A11Phcunt '.
Fy PERMIT ISSUANCE' 6.00 FL000 ZONE AA-U.C.CCCF:HI [CAT F.OE1IIOTIN INSNPROM WOHKIiRS'
OJ > COMPENSATION PLG.CONTR. LIC.NO. PLG.
d O ( is section need not he completed if lire TNnmil is for one TOTAL Y ElN❑ Y C1N❑
Da
O Z hundred dollen IS 100t.,hos.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall-not employ any person in any manner w as to
U hecome winter to the Worken'Compenation Laws of California.
O w part A vacant BUILDING
CL p ALTER-OR ADD TO MECH. 4.00
} Vl NOTICI7 TO APPLICANT: It,after making this Ccrtifiealc of Ex
F Z emption,you should become subject to the Worked Compensation APPLIANCE 4.00 PLAN CHECK
provisions of tie Labor Code, you must forthwith comply with FEE
U such provisions or this pemsit shall be deemed revoked AIR HANDLING UNIT(TO 10f100C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IOAWC.F.M.) 5.00 SEISMIC FEE a�
1 hereby affirm that there,:: a ecosirudion lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the wurk:for which this permit is Posted(Sec. MICROFILM
3097,CR.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT IO VER 100,ODOB.T.U.)7.50 ELECTRIC
LII Add rtss
I certify that I have read misapplication and slate that the above VENTILATION FAN (SINGLE) 3.00
intnnnalimi R correct I u,,ca to comply with all city and county PLUMBING
ordinances and state laws rebtingfo building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
'hereby authuriae representatives of this city to enter upon the BOILER-COMP(Over IddO)OBTU)SEE FEE SCH. MECHANICAL
alwvementioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino ayina Babilitice, judgments, costs and expenses which CONST.TAX
Party in any Way•ucc cages' st said City in corecquence of the PERMIT ISSUANCE 3.00 s
.runt....o.this pet . MELH.CONT. LIC.NO, MECH.
TOTAL TOTAL �
r SigneIare CfA 'in NTMI , Del '
OFFICE COPY