5816 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
AD /7��>< �, 5 816
. BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
N. 'S PLAN CHECK VALIDATION
rvA TY. ELECTRIC PERMIT FEE
� wVy��HDNEY�1 z-�
NEMER Toes UTLETS-SWITCHES-RECEP 5.00/1.00
LIC.No. ILIGHTING FIXTURES 5.00/1.00
nooeess TOB$ • PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 DATE OF APPLICATION
ARRCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.N0.
ENGINEER -
uc.NO. SIGNS TRANS. 3.00
ADDRESS ENG SPECIALCIRCUIT 5.00 PERMIT VALIDATION
zIv TEMP.METER OR POLE INS. 15.00 - r/34
APPLICANT'$ADDRESS MOTORS � SEE FEE SCH.
SERVICECHANGE 10.00 �
FOO LICENSED CONT'RACTURS DECLARATION "
a v I hereby Billion OUR I am licensed under provisions of Chapter 9 -
A Q w ISSUANCE GATE
Professions C with Suction 700e i of Division 3 0(the Business'and BLDG, ELECT, PLG. MECH.
0 y z Professions Code,and my license is in roll force and effect. ❑ ❑ ❑ ❑
Z out - License Class oNumber
Contractor O z r� Dale Contractor
cr cr IS f J
IS BE a OWNER-BUILDER DIiCLARATION + BUILDING PERMIT
A °a MISC.- REFER TO ORD INFORMATION
w ;u N I hereby affirm that I am exempt 031.5 the Contractor's License
u O j Law For the followin•reason.(See 703 t.5,Business and Professions VALUATION $/FT.
- h PERMIT ISSUANCE 6.00
my Code:Any city or county which rcquiraa permiuol:onstnm..tier,
IS Q a Q Improve,demolish.or repair By SIryCIUR,prior 11 Its ISIS...cif,also ELEC.CONTR. LIG NQ ELEC.
O u requires the applicant for such permit to file a signed statement that
i w om u - TOTAL PERMIT TO
he is licensed pursuant In Eng provisions of the Cont Division
License MEL
r z a Law(Chapterand
Processions Codewith Section is 00)of exempt therefrom the
M 4 O Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
ILHp by any
basis for the fora ermit cube Any a lationp,dica .1 na cion 7O3LS STORIES TYPE CONSTR.
n ; by any applicant fora permit subjectsthe$5001licam Ina civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(8500).): '
❑ I,as owner the property,or my employees with wages as BACK FLOW PROTECT. DEV ICE 2.00
inter sole compensation,will the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered (See.for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
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 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 1 NC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.)' 1,00
builder will have the burden of proving that he did not build or PC- BUILDING USE
prove for purpose ofsale.). RES IND CON PB Ome,
❑ I,as owner of the y contracting with INDUSTRIAL WASTE INTER. ❑ ❑ ❑ ❑ ❑
property,and exclusive) 20.00
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1,00
contracts for such projects with it contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.20011/8.00 TRACT NO. PARCEL NO.
❑ I am esempt under Sec ,B.&P.C.for this WATER HEATER W/VENT
7"
reason 4.00
ownl.r al WATER SYSTEM 4.00
ACC.GATE ACC.FILE NO..
woR' :RS'c IiNSAT10N DECLARATION WATER TREATING EQUIP. 4.00
Wo IT V' RS,C ofr '
I hereby ulfinn that 1 have a certificate of cumI to eel Ginsure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lub.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished.
Z 2 ❑ Certified copy is filed will, the city inspection division. RESPRINK ENERGY T-24
Applicant MISC.- REFER TO ORD. FIY❑ N❑ Y [D N[]
F- �' PERMIT ISSUANCE
LU - CIi R'I'IFICATE OF EXEMPTION FROM WORKERS' 6.00 FLOOD ZONE A.L.U.C.
W COMPI!NSATION INSURANCE; PLG.coNTR. LICL 0C.No. PLG.
('I his .section need not be completed if the permit is for one TOTAL Y❑ IN V[:] N�
2 hundred'I.]]...($100)or less.)
U O I certify that in the performance of the work for which this per- OTV MECHANICAL PERMIT FEE SUMMARY
LL U not is issued,I shall not employ any person in any manner so as to FEE
O ED become subject to the Workers Compensation L.ws of California.
CL Date Applicant ALTER OR ADD TO MEc�AID 4.00 BUILDING
} to NOTICE TO APPLICANT': If,after making this rs'Certificatelis, ion
F ? anon..,you should become subject In the Workers C011,pensation APPLIANCE 4.00
revisions of the Labor Code, PLAN CHECK
p you must forthwith comply with Mq�.J� FEE
U such provisions or this permit shall M:deemed revoked. AIR HANDLING UNITI .Iry3�(- .00 '
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I^O�l00DC.F.M.),5.00 SEISMIC FEE
- I hereby affirm that mere is a construction lending agency for EXHAUST HOOD(WI 11� IIpQ IfIQ.00
Oho performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). - - HEATING UNIT ITO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE)m3.00 `3 �
• inforation is correct.I agree to comply with all city a. cu PLUMBING
ordinances and slate laws relo
ating to building.construction, and BOILER- 4.00
IPI ewhnrira representatives of this city to ente,upon the
above-mentioned property for inspection purpso BOI LER-COMP(Over 100,000 STU)SEE FEE SCH.
MECHANICAL U'o
(We) agree tst sive, ins,judgments,
y
y and keep harmless the Cit of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and ox pensee which CONST.TAX
may in M way .ecru• •ainst sail ity in consequence of the PERMIT ISSUANCE 3.00 3
\� grans of is pcnnif MECH.CONT LIC NO. MECH.
� f TOTAL 609 TOTAL
a� 810
gnamre Applim nlra lord Date
OFFICE COPY