11441 (2) O �?� �vcr�o"sta�FvT 10"2;x?
APPLICANT TO FILL IN INF MATION WITHIN R D LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATION PERMIT NUMBER
B 11 DING
APPLICATION & PERMIT 114 41
DDRESS
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
wNER's ^' T PLAN CHECK VALIDATION
ME - l.I .JJ OTY. ELECTRIC PERMIT FEE
f
COQVTRACTOWS f UTLETS-SWITCHES-RECEP 10.00/1.00
N ME
LIC.No, LIGHTING FIXTURES 10.00/1.00
CONTRACTOR's PPLIANCES-RESIDENTIAL 4.00
ADDRESS
yH PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0.
on
ENGINEER LIC.No. SIGNS TRANS, 3.00
ARCH,
R. S ENc' PERMIT VALIDATION
ADDRESS OR SPECIALCIRCUIT 5.00
ZIP TEMP.METER OR POLE INS. 20.00
ASMOTORS SEE FEE SCH. p l.�J
ADDREoREsS _-
SERVICE CHANGE 20.00
A
woo LICENSED CONTRACTORS DECLARATION J I te C4 1 5.1
<u U I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
y a w (commencing with Section 7000)of Division 3 of the Business and BnCC f��I�'�`'��j PLG. MECH.
o Professions C / tse is in full f sy1a ef¢ I PL.L U ❑ ❑
2 O"� Numb
License Clas Con factor u� u
9 0 Det _Contractor
a x f BUILDING PERMIT
ir w OWNER-BUILDER DECLARATION INFORMATION
E
3 LL 1- I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
wo¢ Law for the following reason,(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 s OJE/FT
r- Code:Any city Or county which mquiresapermit toconstruct,alter, D
a EIEC.CONTR. LIC.NO.< p improve,demolish,or repair any structure,prior to its issuance,also ELEC.
O = requires the applicant for such permit to file a signed statement that TOTAL p T
A w$ he is licensed pursuant to the provisions of the Contractor's License
Fii Law(Chapter 9(commencing with Section 7000)of Divi,i.n30f II1C
z Qo Businessand Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ I-$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
aI-- by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sale compensation,will do the work.and the structure is not
intended or offered for sele (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Lew does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.DD SO,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided(hat such improve-
mentsarenotinlendedornffered for sale.If,however,the building GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or am.. RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Bu,ioC,s LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Lew does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contmemns)licensed plumant to
the Contractor's License Law. SEWER•SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM - - 5.00 ACC.OATE- ACO FILENO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate ofconsent to self-insure,
ar e certiifligcjalee roof.�W1orrkkers'Com�peennsatatiioonnIInsurance.or a�c/errtti flied ZONING - ENG.SITE NO.
Policy
Nd$I7Q2�smpa;Y�feP/�- '-'/•-'��
O / O Cemifiedcopytsherebyfurnished. FIRE SPRINK ENERGYT-24
Z Z ❑ Certi d Is fey a It 'n. c division.
O Applicant MISC.- REFER TO ORD. Y❑ rv❑ v ❑ N[]
rn PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU j CtiRTI PICCOM COMPENSATION
INS PROM WORKERS'
UJ COMI'IiNSAI'ION INSURANCE: PLG.caNTR, LIC.rv0. pLG.
CL O (This section Reed not be completed if the permit is for one TOTAL v❑ N❑ V[:] N[3
D Z hundred dollars($100)or less.)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued.I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California. OO
W Date-Applicant BUILDING
aALTER OR ADD TO MECH. 5.00
} to NOTICE TO APPLICANT: If,after making this Certificate sa Ex-
H ? empision You should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
Provisions io the Labor Code, you most forthwith comply wi01 FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000 C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=11F.M.) 6.00 SEISMIC FEE - CZ / 0
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name - - HEATING UNIT(OVER 100,000 B.T.U.)9,50 ELECTRIC
Lender's Address
1 certify that 1 have read Ilus application and ,are that the above VENTILATION FAN (SINGLE) 4,00
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP 13 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of (his city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of misc.- REFER TO ORD.
Cupertino age iabilities,judgments, costs and expenses which CONST.TAX
may in anyway ccme against said Citequence of the PERMIT ISSUANCE 10.00
granting /this p rmit. MECH.CONT. LIC,NO, TOTAL �Q
is
TOTAL QS /
'Si Nreo Applican Comtracto Ua
OFFICE COPY
1