4693 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 4693
ADDRESS
f JA BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OW NEP'$ PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
• ONE
CONT ACTORS OUTLETS-SWITCHES-RECEP 5.00/1.00
NAME
r ) ( ) LIC,ND, ILIGHTING FIXTURES 5.00/1.00
res
RESS
r-Y
9rv,TRACTOR'S PPLIANCES-RESIDENTIAL 4.00
Vt6J :�f IAS vN-.+ "2off E PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO,
OR
NGINEEq
LIC.No. SIGNS TRANS. 3.00
E0.
ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00 ,r `
APPLICANT'SMOTORS SEE FEE SCH. l/-0`r,✓.-�'"-`_.
ADDREaS
SERVICE CHANGE 10.00
� 02 LICENSED CONTRACTORS DECLARATION
G. II, I hereby aftirm Thal I am licensed under provisions of Chapter 9 ISSUANCE DATE
Z w o, nmu•ooing wtil S tlDn 7BOLH f Di imon 3 of tireBusiness nal SLOG. ELECT. PLG. MECH.
wi I rotcssions Cod t d rrd 1'mns is in lull(or ;'�rpl'�0- - ❑ ❑ / ❑
o m - License Cl, CL'\wnber /
Q z U t Clinometer-, -
< ys - BUILDING PERMIT
¢ ¢ w a OWNER-BUILDER DECLARATION
MISC.- REFER TO ORD INFORMATION
3 1 hereby affinu [hut I um exempt from the Conl ruclore Licauc VALUATION
F .Loj Law for the following reason.(Sec.70315.Businessand Professions PERMIT ISSUANCE 6.00
Code:Any city of county which requires a peril to Construct,alter,
¢ a O improve,denuslish,or repair any sVuct are,PI'ior to its issuaELEC.CONTE. LIC.NO.nce,oleo ELEC.
- 0 ¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
wm¢ he is licensed pursuant to the provisions of the Contractor License
H z a Luw(CImpter9(commencing with Section 7000)of Division 3 of theBusiness and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢ r p the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
aim by eylnP,heafor a permit subjects lhea,licunt to acivil Penalty
nt ALTER-DRAIN & VENT-WATER (EA.) 4.00
of not more than five hundred dollars 155001.1:
❑ 1,as owner of the property,or By em ploy'ecs with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole connpcnsation,will do the work,and the structure is not
Intended or offered for sale (Sec. 7044, Business and Prot'essmns 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 docs such work FIXTURES-PER TRAP 4-00 sa FT PaooR AREA TOTAL ACREAGE
himself or through his own cmployecs,provided flat such innPDGe-
mcntsarenotintended or offered for sale.If.however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or im,owentenf is sold within one year of completionthe owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that lc did not bond or inn- RES IND CON PB Omar
prVee for purpose ofsale.L INDUSTRIAL WASTE INTER. 20.00 - ❑ IN El❑ I,as owner of tire m
e property,aexclusively contrucling with
El 0
lieenwd mm moors to construct the project ISee. 7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:1 he Committal',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 fur such projects with a conlraclnnO licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL No.
❑ I an exempt under Sec.-,BAP C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM - 4.00 H'(ft ACC.DnTE ACC.FILE NO,
WORK ERS'COMPIiNSAI ION DIHMARA'IION WATER TRE1ATLI,NG EQUIP. 4.00 .
I hereby affirm that I have a certilicateafconsenl tosellinsure. ( L` 1 �O.l F.J/li`..V'
or a cerlif¢ate of Workeri Comp'nsation Insurance,or a certified ZONING ENG,SITE NO.
L 'opy thereofa�S�-c�'3✓j'0Q Luh.C.). -
policy No_ y�yg.6fipany
0 ❑ Lrt1eA opy is hereby turn,,Led, (, I/ y FIRESPRINK ENERGY T-24
-:-z &CcrUfied; op I Glcd. w 11 -tl mit 'uSV'etinn•liyii n,i _ ., ,.r -
Fp�- 'Applicant •l rVlr+ 1 . C MISCO-, ... REFER TO ORD` IYQ NQ ' vp N�
CC y CE R1'll'1CA'1'1:OP 17 EM PITON PROM WO R R E RS' '-PERMIT ISSUANCE 6.00 0' FLOOD ZONE A.L.0 c.
LU CO%IPENSA TION INS U RANCE PLG.CONTE. LIC.NO. PLG. I� Y� NE] Y� N�
0' 0 This section need not he completed it the peril is for one TOTAL /f/
:D Z hundrul Aollucs(S 1001 or IeasJ
U O 1 certify that in the performance of (lie work for which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any Inunnenso us to -
U become object to the Worker Connpensation Laws of CBlil'orma.
CL W Dat`' Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} to NOTICIi TO APPLICANT: If,aftermaking this Certificate of lis-
Z iRption,you Should bceonw subject to the Worked Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deenmd revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 3.00
CON'STRUC'TION LENDING AGENCY AIR HANDLING UNIT IOVER 10=C.F.M.) 5.00 SEISMIC FEE
1 hereby affirm that them is a construction ltm4rg agency for EXHAUST HOOD (WITH DUCT) 2.00
the perlbranee of the work for which this peril is Issued(Sec. MICROFILM
3097.Civ,C.L 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
Icertify that l have read lluisapplicalmn and slate thmthe above VENTILATION FAN (SINGLE) 3.00 /
information is correct I agree to comply will all city and county PLUMBING Q
ordinances and state laws relating to building construction,and BOILER- H.P.or 100,000 B.T.U.1 4.00
hereby arlhorim representatives of this city to corer upon th° BOILER-COMP(Over(00,000 BTU)SEE FEE SCH. MECHANICAL
above-men Gond property for inspection purposes
(We) agree to save, indannify and keep harinlcss the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in coueqBen
In of lire PERMIT ISSUANCE 3.00
granting of this permit, MECH.CONT. LIC.NO. MECH. '.�.
OTAL TOTAL
Signxduc ofApplicont/Contractor LA,
INSPECTOR COPY