1792 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI_ POINT PEN ONLY
BU I LD ING PROJECT I DENTIFICATI ON PERMIT rvumeER
k 3DILOING APPLICATION & PERMIT 'I 7 [l
AOORESS I I J
p BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
�(. NAMERS PLAN CHECK VALIDATION '
QTY. ELECTRIC PERMIT FEE
PHONE
CONrRAcroRs UTLETS.-SWITCHES-RECEP 5.00/1.00
NAME
P ucNOLIGHTINGTIXTURES 5.00/1.00
, ,
CONTRACTOR S J PPLIANCES-RESIDENTIAL 4.00
PHONE - PANELS . 5,00 DATE OF APPLICATION
ARCHIL FCr SIGNS 6:00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CU T 5.00 PERMIT VALIDATION
ADDRESS
zip TEMP. ME&.R OPVPOLEPS. 15.00 n �j
APPLICANTS
ADDRESS CH.- MOTORS SEE FEE S ✓l//� f/
SERVICE VANG4O 10.00
wO o LICENSED CONTRACTORS DECLARATION
<
or v I hereby afllrm that I am licensed under provisions of Chapter 9 - 'ISSUANCE DATE `
omencmg witll Seaton 7000)of Division 3 of the Business and BLDG. ELECT. PLC. MECH.
F w z Professions Code,and my license is in full force and effect. ❑ - ❑ ❑
Z, O - License Claz 'y0-Lic.Number J -
9 H o Date Contractor j _i Y� -
5vG, `BU ILDING PERMIT
rc Q w a u'�i*k eUlLufik oliCL�nTi�N i INFORMATION
WO u i_ I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
3 u y .VALUATION S/FT.
H .. o a Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 6.00 '- .4
mo Code:Any city interiorly which requires a permit toconan¢Lubec 600
QQ improve,demolish,or repair any structure,prior to its isaancc,also ELEG CONTR. LIC.NO.-. ETEC. O
va - u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n w Ile is licensed pursuant to the provisions of the Contractor's License /
rz 'A Law(Chapwr 9(commencing with Section 7000)of Division 3 ofthe �j G -
- < Nosiness and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
E x o_
r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any ippliermI tar a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER IEA.) 4.00
of not more than five hundred dollar,(S500)J:
❑ Las owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2,00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the it
mare is not
intended or offered for sale (Sec 7044, Business and Prol-essions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 -
Code. The Contractor's License law does not apply man owner of
property who builds or improves thereon;and who does such Work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
ments are not intended or offered for sale.If,however,the braiding _
or improvement is sold within one year of cmnpletlon, the owner- GAS-EA.SYSTEM-OVER4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build m int
-prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB, Omer
❑ 1,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.
and Professions Code:"fire Contractors License Law docs not apply
a '
to n owner of property who builds or improves th,I and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such project,with o comracmr(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ tum.exempt under Sec. .B.&ItC.mr tltis WATER HEATER W/VENT 4.00 '
reason
Date Owner ' WATER SYSTEM 4.00 ACC.DATE ACC FILE NO,
WORKERS'COMPENSATION RECTA RATION WATER TREATING EQUIP. 4.00 -
I hereby affirm that I have a certificate of consent tosell-insure,
certificate of Workers'Comuisation Insurance,or a cerlifed ZOry WG ENG.SITE NO.
p
copy thereof(Sec. 00,Coo...any ).Policy Cen.�0.(Tis here
ny�E L--K
Q fly Cetlilied copy¢hercby furnizhed FIRE SPRINK ENERGY T 24.
Z 0 A plicanl-tificd cnTv` r1 �with �c inspc cion. MISC.- REFER TO ORD. Y ❑ NNE] Y ❑ NN[]cc a CERTI-FICATF-OF EXEMPTION FROM WORKERS, PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LD > COMPENSATION INSURANCE PLG.CONTR.- LIC.NO. PLG,
1 0 (This section need not be completed if,111e prH,H is for one - - - - TOTAL Y❑. N❑ Y❑ N❑
D Z hundred dullara IS 100)nrless.)
U 0 I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
UL H mil is issued,I shall not employ any person in any manner so as to
U become subject to the Workers ns
Compeation Laws of California.
U u Date ApplicantALTER OR ADD TO MECH. 4.00
BUILDING
} rn NOTICE TO APPLICANT': If,after making this Certificate of
Ex-CRI you should become subject to the Workers'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 deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10fMC.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 the work for which this permit is issued(Sec. HEATING UNIT (TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Cw C.). --
Lcodet•sNanle
LII Address
HEATI NG UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC„ QV
I certify than have read this application and state that the above VENTILATION FAN (SINGLE), 3.00
0 information 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 to enter upon the BOILER-COMP (Over 100,000BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless 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 consequence of the PERMIT ISSUANCE 3.00
granting Of this Permit. -/ MECH.CONT. LIC.NO. MECH.
/j���-ry 611.,I� DTAL
.TOTAL �sOO
Signature of Applicant/Contractor )me
OFFICE COPY