18813 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
a BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING r APPLICATION & PERMIT q �0� f�
1 (� a BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 10 J
OW R'S
N �1 PLAN CHECK VALIDATION
QTY. ELECTRIC PERMIT FEE ;
CONTRACT 's
NAME; OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.Nto LIGHTING FIXTURES 10.00/1.00
ANTRA OR's /,,`�,{l/�� APPLIANCES-RESIDENTIAL 4.00
np to T , ` vlloQ�l �',,,�;J� PANELS 10.00
DATE OF avvLlcarloN
ARCHITECTa v PLAN CHECK FEE P.C.NO.
on PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.no. SIGNS TRANS. 3.00
nmHEss ENG' SPECIALCIRCUIT 5,00 - PERMIT VALIDATION
APPLICANT s ZIP EMP.METER OR POLE INS. 20.00
ADDRESS
MOTORS SEE FEE SCH. L
ORsss
SERVICE CHANGE 20.00 TDe� _
Ey ¢z �`aT39-lulu
Hoo LICENSED CONTRACTORS DECLARATION
Q i>U I hereby ufFrnt fit., l am'licensed under provisions a1'Chapter 9 I I1 N 0 `2 'I•it ) ISSUANCE DATE
y a N (commencing with Section 7000)of Division 3 of the Business and - - BLDG_ ELECT. PLG. MECH.
H w z Professions Code,and my license is in full R rtrtryryff �ITY-a,t�
zo i o License Class Lie.Rwnbcr��}S- ❑ - `P
H w j Date Contractor_ ((�� .Y- air, Elf rrInartif10
a see £ BUILDING PERMIT
EC ¢ a OWNER-BUILDEK DECLARATION
A o d U INFORMATION
w 3: LL w I hereby affirm that I am exempt from the Contractor's License, MISC.- REFER TO ORD
Fu- Law forthe followingreason.(Sec.7031,5.Business and professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
Code:Any city or county which requims a permit to construct,alter,
¢ va Q p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O LL requires the applicant for permit m file a signet statement that TOTAL PERMIT TQ
d w m he is licensed pursuant to the provisions of the Contrnemr's License ❑iL_t,.
H z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe Q-
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation OI Section 7031.5 SIFORIES TYPE CONSTR.
a3t2 by any applicant for a permit subjects tele applicant tux civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).);
❑ I,as owner of the property,or my employees with wages us BACK F LOW PROTECT. DEVICE 4.00 - OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for suit, (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP5.00 Sa.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such unprove-
mentsurcnotintendedOunlfcr«I for sale.11,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one ycdr of completion, the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or int- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,as owner of the property,um exclusively contracting with ❑ ❑ - ❑ - ❑ ❑
licensed cmitractnn to construct the project(See. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. ' 6.00 ASSESSORS PARCEL NO.
and Prolessiuns Code:Thu Contractor's License Low docs not apply
to an owner of property who builds or improves(hereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 -'
e.nl,,cl,for such projects will)a contractor(,)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. 'PARCEL NO.
❑ I:un exempt under Sea It&P.C.ILr th'v WATER HEATER W/VENT 'Z=
reason
Owner Ube WATER SYSTEM 5.00 ACC.DATE ACD FELE NO.
W'ORKE RS'COMITNSA'I ION DECLARATION WATER TREATING EQUIP. 5.00or a -
I hereby afOrm t or huvc nil),u talion nl'consvnt m sclort rq _ _
certificate tcof Workcri hall
). sution Inwruncc,seramrf lflcA ZONING ENG.SITE NO.
copy Ih coalf(Sec.3 ecu I,i...y ).
Policy No. Company _
O Cl Cendiud copy is herchy flrni,li.1 FIRESPRINK ENERGYYT-24
Z Z ❑ Certified copy is filed with the city inspection divisio
O Applicant n. MISC.- REFER TO ORD. y v E] N❑ ❑ N❑
w CERI'IFICA'l 1;017 EXEMPTION FROM WORKERS' PERMIT ISSUANCE 4"0 FLOOD ZONE A.L.U.C.
LU > CONIPBN'SATION INSURANCE PLG.CONTR. LIC.NO. - PLG.
d_0 (Thi, seclidn need not be cmnp clod if the Permit is for one TOTAL t' .00 Y❑ NE] Y E] NE]
Z hundred dolLns IS 100)or less.) -
U O 1 certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U
mit is issued,I shall not employ any person in any ntunner m as to
become subject to the Workcri Compcmulion Laws of Calil'orniu.
Ui Date Applicant - BUILDING
} N NOTICE TO APPLICANT: IL after making this Cerlificate of Ex. ALTER OR ADD TO MECH. 5.00
Z emotion,you should become subject to the Workcri Compensation APPLIANCE '5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply wifll FEE
U such ,hvo
provide.,or this,permit all be dccd rcvaked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONST RUCTION LI!NDING AGENCY AIR HANDLING UNIT(OVER 10)"C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm mal there i, a consvuclion lending agency far EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(See. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lunder',Name
Add
Lender i Address HEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify That I have rood this application and stmt,anu the above VENTILATION FAN (SINGLE)' 4.00 -
information is correct. 1 agree to comply with all city and county BOILER-COMPOH.P.or 100,000 B.T.U.) 6.00 PLUMBING r a
ordinances and slate laws relating to building construction. and
above mentauthioned
representatives for ins of this city to enter upon 1h4 BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
hereby enlioned property for inspection puity to.
(We) agree to save, indemnify and keep IlannleA the City of MISC.- REFER TO ORD. '
Cupertino against liabilities,judgmems, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
ay in any way accrue against Said City in consequence of the
mmm oft is permit. �t MECH.CONT. LIC.NO. MECH.
� 9• TOTAL I r, T
Signature of App hcan Con�tor Date TOTAL 'YI•�V
OFFICE COPY