5111 7 .
.SEIPPLICANT TO FILL IN'INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
. • BUI LDI NG PROJECT 1 DENTI FICATION - PERMIT NUMBER
I BUILDING APPLICATION & PERMIT ^ 1
• r 6DDREss - I I
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
J
- - PLAN CHECK VALIDATION
OTY. ELECTRIC PERMIT FEE
PHONETOR$ UTLETS-SWITCHES-RECEP 5.00/1.00
AC No. LIGHTING FIXTURES 5.00/1.00
CONTRACTORS � �4 DLI' �LOa � PPLIANCES-RESIDENTIAL 4.00
AODRE$S
S PNONE PANELS 5.00 DATE OF APPLICATION
ARCH i c SIGNS _ 600 PIAN CHECK FEE P.C.N0.
OR .
ENGINEER
LIC.NO, SIGNS TRANS. 3.00 ,
WICK OR ENG. ' PERMIT V/{LIDATION
ADDRESS SPECIAL CIRCUIT 5.001 V) 'DATION
ZIP TEMP.METER-OR POLE INS. ' 15.00
CH. SC /
ADDRESS rs - MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
woo LICENSED CONTRACTORS DFCIARATIONLa
'
u I hereby affirm that I am licensed urtdcr provisions Of Chapter 9 1 U CE
(commencing with.Section 7000)of Dinision 3 of the Business anJ BL ELE PLG. MECH.
F a i Professions Cody�tt77n�sy//nIyy..iilI ens s in full fo;9 ,file
0 o•A - Licens ChisS�ri.?-Con Contract -.y_.y- ❑ ❑ ❑
g H ca o Date Comrdat
Y s BUI DING PERMIT
w OWNER-BUILDER DECLARATION _
w ;LL I- I hereby ail irm that I nm exempt frum''the_Co to.errr's License MISC.,- REFER TO ORD I FORMATION
o. o Law for the following reason.(Sec,7031.5.Business and Professions PERMIT.ISSUANCE YAL ATION S/FT.
E - C Code',Any city or county which requires a permit to construct,alter,
6'�
2 c 0 improve,demolish,or repair any structure,prior to its issuance,alar ELEC.CONTR. LIC.N0. ELEC, A
ca,, req uirciihe applieanl lar such ry'rmi6 I.tlle,a-Signe.)slaannd ilio( 6 _ ,TOTAL �� PERMIT TO
X he is licensed Plmlmnt 6o the provisions of the Contractor's License �SG
HiQ
Law(Chapter?(commencing with Section 7000)of Division 3 of the .- v
i 4 o Business and Professions Code)or that he is exempt thenctrumand QTY. PLUMBING PERMIT FEE
or I- the basis for the alleged exemption.Any violation.f Section 7031.5 - STORIES_ TYPE CONSTR.
i ; _ by any applicant for a permit subjects the applicant to a civil lmnAy ALTER-DRAIN -WATER (EA.) 4.66
of not moa than five hundred donors(5500).):
❑ 1,as owner of the property,or my em ployces with,wags us BACK FLOW PROTECT. DEVICE 2.00 OCG GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not . ..
intended or Uttered for sale (Sec. 7044, Business and Profeviuns DRAINS-FLOOR,ROOF;AR EA,CON D. 4.00
Code:The Contramor s License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 Sn FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such irruptive.
menti are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
or improvement is sold within one year of completion, the owr6er- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or int- RES IND CO PB Oma
prove for purpose of sale.). - INDUSTRIAL WASTE INTER. - 20.00
❑ I,as owner of the properly,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1'INC 5 V.B. - 5.00 ASSESSORS EL NO.
,i and Profeviuns Code:The Contractor's License Law docs not apply
5 to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contract.,',License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under See. .B.&Poco bon this WATER HEATER W/VENT 4.00
rcusun
Owner Date WATER SYSTEM - 4,00 ACC.OATE ACC.FILE-NO
.
WORK HRS'COMPENSn'I[ON DRCLARA'NON WATER TREATING EQUIP. 4.00
Hereby affirm that I have a certificate of consent to sell'aimma.
or a certificate of Workers'Compensation Insurance,.r a certi0ed ZONING ENG.SITE N0.
copy thereof(Sec.3800,Lab.C.T
Policy No. Company
O ❑ Certilir c pyishcahyfurnished. FIRESPRINK ENERGY T 2e
Z 2 l ❑ Ccrtifi• r y fil��ialtl d1 inspection disnaml. MISC.- REFER TO ORD.
O ApplicantL r s V❑ N❑ Y N❑
~ ran V PERMIT ISSUANCE 6.00 FLOOD ZONE A"L.U.C.
CC CI'RTIFICA Ii P EXEMPTION FROM WORKERS'
W � C ENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. - Y❑ N❑ 'Y❑ rv❑
CL O (Thu section need not he completed if the permit n for one TOTAL
::) Z hundred d.11W -(SI00)of Las.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
lL F- mit is issued,1 shall not employ any person in any manner so as to
U become subject to the Workers;Compensation laws of Calit'omiu.
a Date-Applicant" ALTER OR ADD TO MECH. 4,60 BUILDING
} N NOTICE TO APPLICANT: If,alter making this Ccrtiftrate of fix.
Z empIion,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MCF.M.) 3.00
CONS1'RUCfION LENDING AGENCY AIRHANDLING UNIT(OVER 10=CEM.) 5.00 SEISMIC FEE
I hereby ulfrm OmI there is a construction lording agency for EXHAUST HOOD (WITH DUCT) 2.00
the perlumwnce pf the work for which this pennit is issued(Sec. MICROFILM
San,Co.(:.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
., Under's Name - HEATING UNIT(OV ER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that I have read this application and sole ilia,the above VENTILATION FAN (SINGLE) 3.70
� information is correct: I agree to comply with all city and mmrty PLUMBING
tl ordinances and state laws Relating to building,construct ion, and BOILER-OO P(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the 801 LER-COMP (Over 160,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for impaction phrposcs.
(We) ayssx to save, indemnify and keep harmle'a the City of MISC. REFER TO ORD.
Cupertino against liabilities,judgments,costs and,expenas which - CONST.TAX
may iI any way accrue ni cqucnc again 'd Cily N consof the PERMIT ISSUANCE 3.00
gra gof this panMECH.CONT. LIC.NO. MECH.
�2 TOTAL TOTAL
Sigilroo,o' tili.vnt/Commictor Dat
.OFFICECOPY `