7056` APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDIDDRESSNG --ill - ,8APPLICATION & PERMIT
n -ELECTRICAL-PLUMBING-ME
CHANICALBUILDING
O UM=�ICa 7056
OWNER'$ PLAN CHECK VALIDATION
NAME 90,tI CITY. ELECTRIC PERMIT FEE
• a{ L' PHONE
ANrnacT Rs
NAME UTLETS-SWITCHES-RECEP 5.00/1.00
/jJ {lj` U LIC.NO. IF LIGHTING FIXTURES 5.00/1.00
CONTRACTOR 4 PPLIANCES-RESIDENTIAL 4.00 '
ADD
BESS �/S- -4'r'4 S
U W6LL PHONE PANELS 5.00 DATE OF APPLICATION
PLAN CHECK FEE P.C.NO.
OR ARCHITCCT 1 SIGNS 6.00
A
ENGIrvEEn
:M11 `L' GW1 uC.ND. G SIGNS TRANS. 3.00
AD14
DRESS EN¢ SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
(D�LD,R, CSVRL NG AME CA
�Tse c. ; ,c 2 nP j. EMP.METER ORpOLE INS. 15.00 ^ y/ r
ADDRESSTa MOTORS S SEE FEE SCH. (\/VT/\1 fj ___,
SERVICE CHANGE 10.00
FOS) LICENSED CON'I'RACI'ORS DITLARA'I'ION
a v U I herehy affirm that I:un licensed under provisions of Chapter 9 ->•� ISSUANCE DATE
tA Q w (commencing with Ser'lion 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
Pmlessions Cod and my license is in full force and effect.
a o m z License Classji3O 11 Lic.Number�"+!f�Lj ❑ ❑ ❑
Q r Date Contractors
` ,,
a E INC- BUILDING PERMIT
¢ ¢ w ¢ OWNER-BUILDER DECLARATION 1: INFORMATION
MISC.- REFER TO ORD
K 3 v, 1 hereby aflinn that I ant exempt from the Contractor's License VALUATION $/FT.
F u• o ¢ Law lin the following reason.(See.7031.5.losinesxand Professions PERMIT ISSUANCE 6.00
Code:Any city or county which rcquims v permit to mnstrucl,alter,
¢ ¢¢ improve,demolish,or usi any structure,pre r its issuance,also ELEC.CONTR. LIC.NO. ELEC., -
¢ rciluirts the applicant lOr such permit to file a sib d statement that TOTAd / PERMIT TO
a w y he is licensed pursuant to the provisions of life.Coe tractors License
� z>
Law(Chapter 9(commencing with Sect ion 7000101'Division 3 Drum
¢ Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
'¢ r o Bre basis for life alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
s '3 '$ by any'applicant]or r permit subjects the applicator a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollrrs($500)J:
❑ I,as owner.1 the property,or my en.ployces with wages as BACK F LOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
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:l'he Contractors 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
s • himself or through his own anployess,provided that such improve-
...cuts are net intended or offered for sale.If.however,the building GAS-EA.SYSTEM-l1NC.40UTLETS 4,00
or improvement is sold within one year of completion, the owner- GAS-EASYSTEM-OVER 4 (EA.) 100 BUILDING USE
builder will have the burden of proving that he did not build or im- . . .
RES IND CON PB amen
C3 1,
for purpose of salef. INDUSTRIAL WASTE INTER. 20.00 1:1 El C3 El 111.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 ASSESSORS PARCEL NO.
an J Professions Code I lie Contractors 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 lin such projects with a contracoms)licensed pursuant to
the Contractor's Lie enn•Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. .B.SP.C.for this WATER HEATER W/VENT 4.00
reason
Owner hate WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
` WORKERS'COMPENSA I ION DECLARAI'ION WATER TREATING EQUIP. 4.00
1 hereby alfam Hurt I hm'o a certificate of consent to Self-insure. ZONING or a certificate of Workers Compensation Insurance,or r cert it slid ENG.SITE NO.
copy thereof ISee.3800,1.a1 C,). '1_.n
Policy ls, } �SConmunY C(\y fi
O ❑ Cern ile,l yery is herby rmshcd. FIRE SPRINK ENERGY T 24
Z Z ❑ Ccgi C tpy I. )i4d wi(I th•�EiC inspection division. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
O Appleton 4"d V N Y N
F ro la�k.J nR[Z Tu W tJi . INC• PERMIT ISSUANCE 6.00 F400D ZONE A.L.U.C.
- CI:RI l'1GA I:O Ii31?M''1'10 1.BONI WORKERS'
U3 > C)MPENSA'I'ION INSURANCE PLG.CONTR. LIC.NO, PLG.
EL O T is section need not be cunt pleted if the pcullit is for one TOTAL Y❑ N❑ Y ❑ N❑
Z) 2 hundred dollars 151001 or le,ss,)
U O 1 certify that in the Pei-t'orntane,of Hue work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
_ LL 1- Iiit is issued, I shall net employ any person in any manner so its to
U hecmne eobject to life Workers Cempcnsution Lnwsof Califmnir.
wa Dec' Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} DO NO CI: '1'O APPLICAN'1: h,ufmr making this Certificate of lix-
F ? 'empt ion,yru.slssndd become subject to the Workan'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you nest forthwith comply with FEE
_ U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONS RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby aflinn that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the peffornnacce of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC 3
Lender's Addre
1 certify that I have read thisipPlication unit state
tliat the abovnte VENTILATION FAN (SINGLE) 1, 3.00
information is correct. I agree to comply with all city unit couy PLUMBING
• ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T:U.) 4.00
hereby au Diorite representatives of this city to elver upon the BOILER-COMP (Over 1100,000 BTU)SEE IEEE SCH. MECHANICAL
abovrmeolioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of I MISC.- REFER TO RD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against d ly n consequence of the
ramin Ihi�ry�r It. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Sgnalurc of Applicant/Contractor Uate
I INSPECTOR COPY