2980 /APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI.- POINT PEN ONL
BU I LD ING PROJECT IDENTIFICATION P T MBER
aWL01NG APPLICATION & PERMIT 2980 980
A'DRESS y
� BUILDING ELECTRICAL-PLUMBING-MECHANICAL
OWNER PLAN CHECK VALIDATION
NM^ N DTV.
"AME '1ELECTRIC PERMIT FEE �•
N- I' PHONE
CONTRACTOR'S
N E ^� �.+ OUTLETS-SWITCHES-RECEP 5.00/1.00
P it�'/�✓ x,AL+GJ/4, .1 X771 LIGHTING FIXTURES 5.00/1.00
LIC.N
CONTR�AjCTpORS /(//s' f1 Q%_'' PPLIANCES•RESIDENTIAL 4.00
GJIaiJ+yILY`M !V; . PHONE�VI '� PANELS 5.00 GATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ENGSPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 15.00
APPLICANT S
ADDRESS MOTORS SEE FEE SCH. j
SERVICE CHANGE 10.00 / L�b-Vf z
woo LICENSED CONTRACTORS DECLARATION
<ems c~z I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w a a (commencing with Section 7000)of Division 3 of the Rosiness and BLDG. ELECT. PLG. MECH.
D i Professions C, a license is in full fo y'�qq ❑
z O w Licenu Clary[ Lic.Number I'I
j. Date/ I�_Contracmr
a Y < �e.LWN0 BUI +BUILDIRMATI MITio.:„�r a`.f
¢ ¢w< OWNER-BUILDER DECLARATION •?'.tr;�:xINFORMATION+•:@'Y'.�j
AOA MISC.- REFER TO ORD
w u.v-r; I hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.,
H LL 0 j Law for the following reason.(Sec.703 L5,Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requimSa permit toconslruct,alter,
IF 5 ¢G improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
w n o u requires the applicant for such permit to File a signed statement that TOTAL PERMIT TO
e w m be is licensed pursuant to the provisions of the Contractor's License r
aa r Law(Chapter 9(commencing with Section 7000)of Division 3 of the : ;i ys f.., ""` 3 ; ♦ Asa +gy' Jf(,tJ�P�
a Business and Professions Code)or that he is exempt therefrom and QTY:"i n . PLUMBING PERMIT!i, bf 'FEE.'.
¢ I=-$ he basis for he alleged exemption.Any violation of Section 7031.5 .f. L i(h.y-.: 'YA.dc.t„e,�`t.nSrS!'..xo-.. •'i Y.,.! �'A ..- .a L`. STORIES TYPE CONSTR.
by aey.pplic.ntfor a permit subjects the applicant toa civil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
'
of not more than five hundred dollars($500).):
O I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2,00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure Is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve
mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 1 NC.4 OUTLETS 4.00
. or improvement is sold within one year of completion,the owner- GAS,EA.SYSTEM.OVER 4 IEA,) 1.00 BUILDING USE RES IND CON PB Ohar
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.). INDUSTRIAL WASTE INTER20.00
❑ Las owner of the property,am exclusively ting with . El El 11 11
licensed contractors to construct the project(Sec..7044,7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
conlmetsforsuch projects witha contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/6.00 o-� TRACT NO. PARCEL NO.
the Contractor's License Law.
13 lam exempt under Sec. ,B.AP.C.for this WATER HEATER W/VENT PAILA.00
reason
Data Owner WATER SYSTEM 4.00 ACC,DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING ECL4W P.
I hereby affirm that I have a certificate of consent to se f-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Ipa ranee,or certi0e _
copy Cherep(($Fc.3 0 .0). H- Sf$JnJ f L'It o ape m
Policy No.b�• r /
(] ❑ CerUFie copy uh a yf rmshed. FIRE SPRINK ENERGY T34
Z Z ❑ Certif co i it t e city inspection division.
PO PP ca MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
cc CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 _/_1
[ FLOOD ZONE A.L.U.L.
LU > COMPENSATION INSURANCE PLG,CONTR. LIC.NO. PLG. /LL 0
dO TOTAL / Y❑ N❑ Y❑ N❑
(This section need not be completed if the permit is for one ,
L) hu'drertify that in he perfVic i ormance of the work for which this per TV.t 4p il4y-,MECHANICALS RM T r�d,.i't3 §"5) FEEtsF (i'W_14;'"yft:F.EE SUMMARVJ T ,,..ttf
.4t
LL F mit is issued.I shall not employ any person in any manner so as to L
U become subject to the Workels'Compensation Lawsof California.
y Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
OTICE TO APPLICANT: If,after making this Certificate of Ex-
F emption,you should become subject to the Workers'Compervation 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 10=C.EM.) 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,Civ.C.).
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 /
information is correct.1 agree to comply with all city and county PLUMBING
ordinances and stale 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 100,000 BTU)SEE FEE SCH. 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
gjgntin Ithls permit MECH.CONT. LIC.NO, MECH. F�
,:;=c-.y,Nq,(.'1 '
TOTAL ,} ✓' M
T,OTAL :'
�
Signature of ApPlicangCnntmcmr Date y�� ` -",.£%i':^Si
OFFICE COPY