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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUI LDIPIG PROJECT IDENTIFICATION
APPLICATION &PERMIT
BUILDING — ELECTRICAL— PLUMBING — MECHANICAL
-PERMIT NUMBER
6868
U U 8
ADH.mSG J
ADDRESS
/
3 REEK uc� oc R
OwNER'B
NAME /
{ t I 2111 2A IOKD PHONE
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
'
-
DATE OF APPLICATION
CONTNAME
/T &JjerS LIe.No.
OUTLETS UTLETS-SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
DScaDna
ADDRESS -
405 S ,2VIA h V - PHONE -7Z0-05-
APPLIANCES -RESIDENTIAL 4.00
PANELS 10.00
ARCHITECT
OR
ENGINEER KAbzA
D. KF1 IT um. NO.
,.,
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE
P.C. NO.
SIGNS TRANS. 3.00
ARCH. OR ENG. j
ADDRESS 11
D6D /�r� 'tIGW zm
SPECIAL�CIRCUIT 5.00
PERMIT VALIDATION
^—
EMP. METER 08 POLE INS. 20.00
APPLICANTS
ADDRESS
MOTORS SEE FEE SCH.
Z L /��
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
-
- -
1 hereby afNrm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, un my license is in full force un efJ I
License Cass - Lic. Number �J
ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
rtn
❑ ❑ ❑
-
Date Contractor
' OWNER-BUILDERDECLARATION
I herehy affirm that I am exempt from The Conflict or's Licansc
Law for the following rcsoa
a(Sec. 7031.5, Businessund Professions
Cade: Any city or county which requires a permit m construct, altcq
'lfBUILDING PERMIT
INFORMATION
MISC.— REFERTO D
PERMIT ISSUANCE 1 `00
h
R 1`1JH`LUATION
$/FT.
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 91 commencing with Section 1' Division 3 of t he
e
easiness and Professions Code) or thus his exempt
e is exempt therefrom and
ELEC. CONTE. -LIC. NO. ELEC. p�
TOTAL'
PERMIT TO
M�
QTY. PLUMBING PERMIT FEE
of Section 703L5
by basis for the alleged exemption, Any applicant
by any applicant lora permit dollarsthe $500).licant macivil penally
:
allot more than five the
dollars (try
STORIES
TYPE CONSTR.
ALTER-DRAIN-WATER(EA.) 5.00
❑ 1, as owner at the property, or my employees with wages as
prop em
their sole compensation, will do the work, and the structure is not
intendedllor offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
BACK FLOW PROTECT. DEVICE 4.00
-
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 5.00
FIXTURES - PER TRAP 5.00
GAS-EA.SYSTEM-I1NC.40UTLETS 6,00
property.vom builds or improves thereon, and who does such work
himself or through his own employees, provided thud such improve-
mealsarenotintendedoroffered for sale If, however, the building
SQ PT. FLOOR AREA
TOTALACREAGE
or improvement is sold within one year of complelion, the owner-
builder will have the burden of proving that he did not build or int
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
prove for purpose of sale).
❑ E, as owner of the properly, am exclusively contracting wish
RES IND CON PB Other
Q ❑ ❑ ❑ El
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct dile project (Sec. 7044, Business
and Professions Code: The Contractors License Low does not apply
to an owner of property who builds or improves fhercon, and who
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
-
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contractors) licensed pursuant to
the Contractor's license Law.
❑ lam exempt under Sec.—, B.&P.C. for D,is
reason
SEWER -SANITARY -STORM EA. 200ft /10.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 6.00
Owner, Dude
WATER SYSTEM 5.00
ACC. DATE
ACG FILE NO,
WORK ERS'COM PFNSA'I' ION DECLARATION
WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to sel Ginson"
-
ZONING
ENG. SITE NO.
or a certificate of Workers' Compensalion Insurance, or a certified
copy theregf d - J80� Lah.C.l�_'� /_
Policy Nn F UM( W
.,npany (,ttlAyS
❑ Certified copy is hereby famished.-
FJ Cerr:fie s ry 's filed' It the cirY indivision.
haam —ed It
MISC.- REFER TO ORD.
FIRE SPRINK
V E] N
ENERGY T-24
Y ❑ N�
CERTIFICATE OI' EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
1'f his section need not he completed if the permit is for ane
PERMIT ISSUANCE" 10.00
FLOOD ZONE
Y N
A.L.U.C.
Y [] NE]
PLG. CONTE. - LIC. NO.
PLG.
TOTAL
hundred dollars IS 100) or less,)
I certify that in the perfonnance of the work for which this per-
mitis issued, I shall not employ any person in any manner so as to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
became subject to the Workers' Compensalion Laws of California.
Date ApplicantALTER
NOTICE TO APPLICANT: If, after making this Certificate of 17N
ALTEROR ADD TO MECH. 5.00
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10MC.F.M.) 4.00
PLAN CHECK
FEE
you should become subject to the Worker Compensa0mr
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked
AIR HANDLING UNIT(OVER I0J](10C.F.M.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
file performance of the work or which tl' peril is issued (Sec.
3097, Ci, .C.I I Z
MICROFILM
HEATING UNIT (TO 100, 000 R. T. U.) SBO
Lender's Name ', r-
Lender's Address �
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
1 certify triad I have read This application and stain that (lie above
VENTILATION FAN (SINGLET 4.00
information is correct. I agree to comply with all city and county
Ordinances and state laws relating To building construction, and
PLUMBING
-
BOILER- CDMPQ H.P. or 700,000B.T.U.) 6.00
Hereby enthoriec representatives of This city m ever upon the
above-mentioned property for inspect ion purposes.
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
�w
(We) agree 10 save indemnify and keep harmless the City of
MISC. - REFER TO ORD.
Cupertino ugni s1 li litie judgmel S, costs and expenses whish
may in any y en a ainet City in consequence of the
mnli0g ONs it,
/
PERMIT ISSUANCE
CONST. TAX
MECH. CONT. LIQ NO. MECH.
// // STATE TOTAL
7�iAekrXIAW4*1 ? "?
TOTAL
Sign a pp' nt Contractor Dale
OFFICE COPY