7278 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- U ALL POINT PEN ONLY
BUILDING PROJECT IDENTI ION PERMIT NUMBER
f By DING s APPLICATION & PERMIT
ADDRESS
BUILDING—ELECTRICAL—PLUMBING—MECHANICAL7278
• OWNER'a - _ _
NAME PLAN CHECK VALIDATION
QTY. ELECTRIC PERMIT FEE
vlaoNE
NAME CTOR'S
NAME 6,TOUTLETS-SWITCHES-RECEP 5.00/1.00
pN1//i F/ECT. UC.ND. q 0 LIGHTING FIXTURES 5.00/1.00
ADDRESS oWs APPLIANCES-RESIDENTIAL 4.00
gDDflsss
U 44 EV7-L7L14JP PANELS 5.00
ARCHITECT DATE OF APPLICATION
OR SIGNS 6,00 PLAN CHECK FEE P.C.NO.
ENGINEER
AENG. Lm.NO. SIGNS TRANS. 3,00
ADDRESS.
SPECIAL CIRCUIT 6;06 PERMIT VALIDATION ,
ZIP TFMP.METER OR POLE INS. 15.00
APPLICANTS )• U ALE ��/rr r
ADDRESS T E MOTORS SEE FEE SCH.
A/ 01'G C r.(�/�.*7 SERVICE CHANGE - 10.00
woo LICENSED CONTRACTORS DECLARATION
a i w I hereby affirm that 1 am licensed under provisions of Chapter 9
m< T (commencing with Section 7000)of Division 3 of the Business and ISSUANCE DATE
H h 2. Professions Cole an my license is in full force an eff eL BLDG. ELECT. PLG. MECH.
o,i m- License Class Q— Lic.Number. �z�y9 trg ❑ ❑ ❑
Ualc_ =. ./±p_�Contmclor—Y@d1_Ifz} (�[[: `.,
w'- 2
E ¢ w < OWNER-BUILDER DECLARATION FEB BUILDING PERMIT.;sh
u INFORMATION(>
w 3 e F I hereby affirm that I am exempt from the Contractor's License MISC.— F O ORD
u O j Law for the following reason.(Sec.7031.5,Business and Professions VALUATION E/FT.
iw>E Code:Any city or county whichreyuiresapermit toconstruct.alter, PERMIT ISSUAN 6.00
¢ ¢<O improve,demolish,or repair any slmclure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. ^_
DLL requires the applicant for such permit m file a signed statemem that AN A �/ f TOTAL 7�
is w m n he is license)pursuant to the provisions of the Contractor's License [� PERMIT TO
H z a Law(Chapterg(commencingwithScaion701XOofDivision3oflhe TLCG'T
E 4 o Business and Professions Code)or That he is exempt therefrom and QTY. PLUMBING PERMIT —'FEE z
¢s_$ the basis for the allege)exemption.Any violation of Section 703 LS - • STORIES TYPE CONSTR.
n ; by any applicant Toro pertnil subjects the applicanttoacivil penalty ALTER-DRAIN -WATER (.EA.) .
400
of not more Than five hundreJ Jollan($500)):
❑ 1,as owner of Ihe`pfopeny,or my employees with wages asBACK FLOW PROTECT.DEVICE
their sole compensation,will,Jo the work,and the structure is not 2.00 OCC.GROUP RES.UNITS-
intenJed or offered for sale(Sec..7044, Business and Professions
e: DRAINS-FLOOR,ROOF,AREA,COND. 4.00
CodTho Controclor's License Law dos apply to an owner of
properly who builds or improves(hereon,and who does such work F IXTUR ES-PER TRAP 4.00 1 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided&(hot such improve-
mentsarcnorintendedorofferedforsale.l f,however,the building GAS-EA.SYSTEM
-1INC.
4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or im- GAS-EA,SYSTEM-OVER 4(EA.) 1,00 BUILDING USE
prove for as owner of(be p - INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB Omer
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7144,Business LAWN SPRINKLERS-1 INC 5,V.8. 5.00 - ASSESSORSPARCEL NO.
ED
and Professions Code: ['he 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
contracts for such projects with a conlractods)licensed pursuant to
Jim
Con tractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec...B.&p.c.for this
reason WATER HEATER W/VENT 4.00
Owner Uale WATER SYSTEM
4.00 ACC.-DATE ACC.FILE NO.
WORK ERS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm thus I have a certificate of consent to SON
or Or a certificate of Workers'Compensation Insurance,or a cerlified ZONING ENG.SITE NO.
copy thereof(See,3800,Lah.CJ.
Policy No. Company
O ❑ Certified copy is hereby furnished.
z ❑ Certified copy is filed with the city inspection division. FIRE SPRINK ENERGY T-24
F Applicant MISC.- REFER TO ORD. 'Y[:) No Y 0 NN[]rn PERMIT ISSUANCE
QC CERTIFICATE OF SAI IO TINS FROM WORKERS' 6.00 FLOOD ZONE A.L.u.C.
W � COMPENSATION INSURANCE PLG.CONT 'LIC.NO.
d - (This section need not be completed if the mit is for one PLG.
p Per TOTAL Y[ _ No Y� NE)
0 2
handled dollars in the pe fort
U O 1 certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mil is issued,I shall not employ any person in any manner so as to
been my�s�{�'�c lathe Workers'Cyry ensalionJ4ws of Calitornix.
i Lateen'-N- Applicant Iq[+n—+J ALTER OR ADD TO MECH. q.60 BUILDING
} In NOTICE TO APPLICANT: If,after ma ing this Cer dicalc of 1>x-
F _ empticn,you should become subject to the Workers'Compensation APPLIANCE I I
4.00 PLAN CHECK'
provisions of the Labor Code, you must forthwith comply with
C.7 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO lOpODC.F.M.) 3.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of file work for which this permit is issued(Sec. MICROFILM
3897,Cis.C.), HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000B.T.U.)7.50
Lender's Address ELECTRIC �—
ICertify,that l have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
1Oformation is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city Io enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH.
above-mentioned property for inspection purposes. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- r '
REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
. may in any way eccme against mid City in consequence of the PERMIT ISSUANCE 3.00
grantin of this permi '
MECH.CONT. ' LIC.NO. MECH.
t ��'/-�r TOTAL TOTAL;'
"alum of ppllcam/Contract oilUate
OFFICE COPY