1897 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY -1
r BUILDING PROJECT IDENTIFICATION PERMIT r[UMBPR/-/
BUILDING /f / APPLICATION & PERMIT `/�l
ADDRESS f7 / // N / /r �1 U 9 7
J But -ELECTRICAL-PLUMBING-MECHANICAL
6 //
OWNER'S 7 7, 's- � ) °(t ? r PLAN CHECK VALIDATION
NAmE7 OTY. {
.ELECTRIC PERMIT '++I? ( '� ' FEEL
V O N/✓ PRONE
CONTRACTORS UTLETS-SWITCHES-RECEP 5.00/1.00
NAME q
J MZ Iuc.No ) 3 LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
ADD�/RESS
�/r///,,./
(ONE 3,l oo ] PANELS 5.00 DATE OF APPLICATION
ARCHITECTPLAN CHECK FEE P.C.NO.
OR / SIGNS 6.00
ENGINEER
LHC.No. SIGNS TRANS. 3.00
aooeis eea SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 15.00
ADDRESSTS MOTORS / �L SEE FEE SCH. nC�
k 11For II c el,4y SERVICE CHANGE 10.00 fJ
Woo LICENSED CONTRACTORS DECLARATION
La a u U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y<a (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
I
i Professions Code,a m license is in full e eOF I
0 ❑ ❑ ❑
o m License Class Lin.Number,
Z.1- w Date Contractor
BUILDING PERMIT,.'.,,
'
¢ m¢ OWNERB UILDER DECLARATION •-•' I" INFORMATION's:
o " REFER TO ORD VA •a
A. I- I hereby affirm that I am exempt from the Contractor's License MISC.- VALUATION E/FT.
u. 0 Low forthe following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE W 6.00 0J Code:Anycity orcounty which requires a permit to construct.
¢< improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC
ars¢ requires the applicant for such permit to file a signed statement that TOTAL /. PERMIT TO
w S H he is licensed pursuant to lire provisions of the Contractor's License s�9
> Law(Chapter 9(commencingwith Section 7000)ofDivision 3 ofthe cA }`}I -'' v.g "
fE c Business and Professions Code)or that he is exempt therefrom and OTY.y :f i 1 PLUMBING PE RMITI.:".'h I' FEE•
It r$ the basis for the alleged exemption.Any violation of Section 703 1.5 e• ♦ STORIES TYPE CONSTR.
i;_ by any aomthan for five permit dollars(heapplicam toacivilpenalty ./. ALTER-DRAIN -WATER (EA.14.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 / OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor'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 50,FT,FLOOR AREA TOTAL ACREAGE
himself re through his own employees.Provided that such improve.building
hiFIRI mself a not through
orofferedempor loyees,
that such
building GAS-EA.SYSTEM-1INC.4OUTLETS 4.00 CAO
ar improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Omer
prove for purpose of the.). INDUS I TER. 20.00 ❑ ❑ ❑ ❑ ❑
❑ I,as owner of the progeny,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044.Business RI KLERS- 1 INC 5 V.B. 5.00 AssEssD(s PARCEL No.
and Professions Code:The Contractor's License Law does not apply' '
to an owner of property who builds or improves thereon.and who LAWN SPRI VER 5(EA.) 1.00 3 7� --3 d'-
contracts for such projects with a contracions)licensed pursuant to
the Contractors License Law. SEWER'• A ITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ l am exempt under Sec.-,B.&P.C.For this WgTER HEA /VENT 4.00
reason
Date Owner WATER S 4.00 ACC.-DATE ACC.FILE NO.
WORK F.RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to sel Pin%re.
or a certificate of Workers'Compensation nsumnce,or a certI'it ZONING ENG.SITE N0.
copy there f e 800apLab.C.). /IJtkA 5,T
PolicyNV-1 Company w�' „tv
❑ Certified copy is 6ercby furnished. FIRE SPRINK ENERGY T-24
❑ Certified I e fly inspection division.
p Applicant Cs Misc.- REFER TO ORD. Y N❑ ❑ V ❑
� N
CC CER 4ICATEO EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 - FLOODZONE A.L.U.C.
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL Z) Z (This section not be completed if the permit is for one TOTAL �/ •� [DN❑ Y N❑ ❑
hundred dollars(SIO 51001 pe form
U O 1 certify that h the performance of the work for which this per, OTY. MECHANICAL PERMIT FEE FEE SUMMARY
0 f mit is issued,I shall not employ an)' person in any manner as rn
O W becom subject t the Workers'Co nsation aws of Cali Fri
Dam Applicant pe / BUILDING
a �� �- ALTER OR ADD TO MECH. 4.00 '7"� _-
} m NOTI A P CANT: If, r m' m this Certificate o Ex-
F ? empion,you should become s lett IL the 'orkeri Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code. you must forthwith comply with FEE
C..7 such provisionsor this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10J100C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT IOVER 10=C.F.M.) 5.00 SEISMIC FEE v S�
I hereby affirm that there is a construction lending agency I'or EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 /--
Lender's
Address ELECTRIC fJ .�
I certify Ihat I have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
information is to correct.I agree comply with all city and count -PLUMBING [(
ordinances and stem laws relating to building construction. and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 �r
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the Cit'of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which pp CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
granting of this permit. MECH.CONT. LIC.NO. MECH. t" a
-12 TOTAL 7� TOTAL-. X/
Si a ore plicant/Contractor Date
OFFICE COPY