7017 APPLICANT TO FILL"IN INFORMATION WITHIN RED LINES — USE BALL POINT,PEN ONLY
BUILDING PROJECT 1 DENTI FICATION PERMIT NUMBER
APPLICATION & PERMIT O I
alnaolrvc . - _I
aoo REss BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
/D 3 g& Am i:s d C�
OWNER'$ PLAN CHECK VALIDATION
NAME L 3d a ,1 t h 3� R
PHONE
�g fyV k ?'.ELECTRIC P,ERMITT' .ay;'.yx;.*V 1FErvE,�!;
CL/
CONTRACTORS iS20� OUTLETS 5.00I1.00
NAME J lU� ��///��' -
AHas HM sec No'�7/yW: Zl6 LIGHTING FIXTURES 5.00/1.00
CONTRACTORS S7Ar Wyr? PPLIANCES-RESIDENTIAL 4.00
ADDRESS
/1/yy —�Vr� s
PHO lap • PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ON
ENGINEER
LIC.No. SIGNS TRANS. 3.00
nooe'EsR ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANT
AODREAS MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
,02 LICENSIiD CONTRACTORS DECLARATION
��
L/
¢v I hereby affirm Ibut 1'am licensed under provisions of Chapter 9 IS DANCE DATE
G i (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT, PLG. MECH.
F w i Professions Code,and my license is in full force and effect.
z z m W License Class I,ic.Number _ �'Z Ny ❑ ❑
o 2 Date Lic.Nu b
a x f BOILDINO PERMIT
¢ ¢ ¢ OWNER-BUILDER DECLARATION -
o INFORMATION
.W ;LL N I hereby affirm that I am exempt from the Contractor's License MISQ.— REFER TO ORD VALUATION S/FT.
r .. Na Law for the following reason.(See,7031.5,Businessand Professions PERMIT ISSUANCE 6.00
Code:Any city m county which requires a permit to construct;alleq
¢ ¢¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. - LIC.NO. ELEC.
O, requires the applicant fur such permit to lite a signed statement that TOTAL PERMIT
A w m he is licensed pursuant to the provisions of the Contrector's License
R i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofibe "'Ln♦ ,�
z o Ilusess and Professions Code)or that he is exempt therefrom and OTIY,,
°'
i yA+yr° P,LUMBINGPERMIT ,' av„l`j%� FyE ��
m
¢ F o the basis for the alleged exemption.Any violation of Section 7031.5 '' gN n8 s” 16:e I -"'S' _ STORIES. TYPE CONSTR.
aim by any applicant for a peratirsubjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not mom than five hundred dollars(S5006):
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and(he structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 4.00
Code:The Contractor's License Law doss 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-
mentsamnotintendedorofferedforsale.lf,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owne
builder will have the burden of proving(hut he did not build or imr-
- GAS-EA.SYSTEM-OVER 4 (EA.)-. 1.00 BUILDING USE
RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,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 Coda: I'lie Contractor's License Law does not apply - -
t0 an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 -
como ets for such projects with it contradosfs)licensed pursuant to
the Coninlnmr's License Law, SEWER-SANITARY-STORM EA:200ft/8.00 TRACT NO, PARCEL NO.
❑ I am exempt under Sec..,BAP.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4,00 ACC.DATE ACC,FILE NO.
WORK HRS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to sel Ginsum, ZONING
I or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy there /� {.�b�.J� �TL
Policy Noip_iiwj flau)V T (i
0" ❑ Certified c0 is hereby furnished. FIRE SPRINK ENERGY TQ4
�y�/�CertiOe, i H"i1�d�ith the 'iI�p5{',k�c��l��iiyy,q� si MISC. REFER TO ORD.
z p Alfllli cant- _ �r]�� ptef�-(ILSL'`S`'A�l - Y❑ N❑ Y ❑ N❑
H rn F V PERMIT ISSUANCE 6.00
Cr CE 'I ICATIi O h:%IiMP1'ION FROM WORKERS' FLOOD ZONE A.L.u.C.'
LU > COMPENSATION INSURANCE PLG.CONTH. EJC.NO. PLG.
U I This section need not be completed if the permit is for one TOTAL v❑ IN❑ Y ❑ N❑
0 Z hundmd dollars 1$I OOIor frm.)
Y
U O I certify that in the performance of the work for which this per- Jk 1�]QTV:. ""M ECHANICALj4iFEE`A p ''FEE SUMMARV� .
IL H nut is issued,I shall not employ any person in any manner so as Io - I('QNa -
U become subject to the Workers'Compensation Laws Of California.
a Date ApplicantALTER OR ADD TO .00 BUILDING
,} W NOTICE 'TO APPLICANT: If,after making this Certificate cel'Ex-
F ? eiirplion,you should become subject to the Workers'Compensation ApPLI ANCE 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 10nqfA KMDO
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(O O C.F.M.) 5.00 SEISMIC FEE
1 hereby affirm that (here is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance 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
Lender's AddName ELECTRIC
I certify(bat I have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
informordinances
n correct. I agree to comply with all city and county BOILER-CDMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and stale laws'LiesRelating to building construction,upon
and '
hereby authorize representatives ec this city es 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 PERMIT ISSUANCE 3.00 CONST.TAX
-. may in any way aecme against said City in consequence of the —�
gmnling0 -s permit.
MECH.CONT. LIC.NO. MECH. x 'ts .p- '
TOTAL
SignK14 of Appf a 1/Contractor ^Detc v A
OFFICE COPY -