4800 APPLICANT TO.FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
.PERMIT NUMBER
BUILDING PROJECT IDENTIFICATION
BUILDING APPLICATION & PERMIT 4800
ADDRESS
ON Mpfoc BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CNECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
•- LOr� PNOra�+).l ter'^6
CONTRACTOR e_ZO UTLETS-SWITCHES-RECEP 5.00/1.00
ME
LIC.N SS LIGHTING FIXTURES 5.00/1.00
CONTRACTOR (` PPLIANCES-RESIDENTIAL 4.00
V1f PANELS 5.00 DATE OF APPLICATION
RDNrtECT 6.00 PLAN CHECK FEE P.C.NO,
O
DR SIGNS
ENGINEER
uc.NO ISIGNS TRANS. 3.00
ARCHOFI
ADDRESS ENG �_ SPECIAL CIRCUIT S.00 PERMIT VALIDATION
zip EMP.METER OR POLE INS. 15.00
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS /
SERVICE CHANGE 10.00 �/ /'y
Woo LICENSED CONTRACTORS DECLARATION /�7
Fu u 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MEC
zii Professions Code and my license is in full f e and of Sfr,', ❑ ❑ O
o m - License Cla �-�-Lia Number `���_
m i w Dere Contnctor .E
A r`µ.J BUILDING PERMIT.;-
a w WNER-BUILDER DECLARATION ,INFORMATION,'
u N I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
,Loa Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 6.00 VALUATION $/FT.
m Code:Any city or county which requires permit to construct,alter.
M < improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- O M requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
m$M he is licensed pursuant to the provisions of the Contractor's License 1. - ..
Hzr
Law(Chapter 9(commencing with Section 7000)of Division 3 of the P '' �1
i c Business and Professions Code)or that he is exempt therefrom and OTY..�'u •q9.-PLUMBING PERMIT -FEE s;
the basis for the alleged exemption.Any violation or Section 7031.5 wK S. •'.• ei s" `. ,-•^711y. „ _ ;,, u, p tM� bL STORIES TYPE CONSTR+
d; by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.DD
of not more than five hundred dollars(S5000:'❑ 1,as owner of the property,or my employees with wages in BACK FLOW PROTECT. DEVICE 2.00 DEC.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 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve•
mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or . .00 BUILDING USE improvement is sold within one year of completion,the owner- GAS-EASYSTEM•OVER 4 IEA.) 1
builder will have the burden of proving that he did not build or im- RES IND CON PB Otho,
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 El ❑ El ❑ El
1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORSPARCEL 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 SPRINKLERS-OVER 5(EA.) 1.00
contrthe Cont for suchLicenenawithacomradorts)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the Casts fo License Law.
Cl I am exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACL.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a Certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workeri Compensation Insurance,or a cert i fie
Copy ther ggBBO0/IlaIt.
Policy NOkCansp • 1(1 ixG( rt L L
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z 2 Z•Cenified copy is filed with the city inspecti �vlCi MISC.- REFER TO ORD. y N y ❑ N❑
O A plica t ❑ ❑
~ m PERMIT ISSUANCE 6.00 FLOOOZONE A,L.U.C.
CC CE TIFICATE F EXEMPTION FROM 1 ORKERS'
LLIC O COMPENSATION INSUR PLG,CONTR. LIL.NO. PLO. ❑ ❑ ❑ ❑
(This section need not be completed if the Permit is for one TOTAL Y N v N
::) Z hundred dollars 151001 or less.)
CJ O 1 certify that in the performance of the work for which this net, QTY. MECHANICAIa.REi3{t}F'{ - FEE FEE SUMMARY
LL 1- mit is issued.I shall not employ any person in any manner so as to !I�'/W v
U become subject to the Workers'Compensation Laws of California.
LU Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} % NOTICE TO APPLICANT: If,after making this Certificate of fix- _
FZ emption,you should become subject to the Workers'Compensat ion APPLIANCE I" t� - "v '4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply wish FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,00D GF.M.1 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(�j'�,RJOAOO C.f. .00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(See. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100.000 B.T.U.) 4.00 91.12-0
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.17.50 ELECTRIC '-
'.
Lender's Address
• 'I certify that correct.
read
agrees application and all c that d county VENTILATION FAN (SINGLE) 3.00
information is cornet.I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER•CON1P(3 H.P.or 100,0008.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILEfl• OMP(Ove 100,000 TUI SEE FEES H. MECHANICAL
above-mentioned property(or inspection purposes. `-
; '„ (We) agree to save, indemnify and'keep harmless the City of MISC. v F R D.
Cupertino against liabilities,judgments, costs and expenses whichPERMrF ISSUANCE f 12F 14:00 13 Z"`7 CONST.TAX
may in any way accrue against said City in consequence of the
B tin Pf Ili' permit. MECH.CONT. LIC.NO. MECH. f.'FaT)6' FiM`I' rL' i
TYITAL^Iri5rD a DOTAL t .
azure of i nt(CIT tract Date a /`Is••�-/ A Z.SS / (V�l(JJ 5V'.." 3 - t•c.
OF ICE'COPY