6054 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT•PEN ONLY
BUILDING PROJECT I DENTIFICATION - - PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
` BUILDING-ELECTRICAL=PLUMBING-MECHANICAL 6054.
OWNER'S.. v' + '� " 11 - PLAN CHECK VALIDATION .
N ME /r• \\ _ 4TV. ELECTRIC PERMIT - - 'FE .
Os V'a�d Y/w.+n PHON �'6 k''fx�a,a:s°,s.r x e„a.t*'».m„°#Nae1e a�v ..0 w x .
CONTRACTOR'S
,,,y7� - ppUTLHTETS-SWITCHES-RECEP 5.00/1.00 .
JT�Y [N JI ��gL)• 'LIC)NO. p^ LIGING FIXTURES 5.00/1.00
CONTRACTOR'S .APPLIANCES-RESIDENTIAL '4.00 -
ADDRESS '1pJ q
3cb $� PHON�}C{��D/ PANELS S.00 DATE OF APPLICATION
ARCHITECT - PLAN CHECK FEE P.C.N0.
OR SIGNS B.00
ENGINEER
LIC.NO. - SIGNS TRANS. + -3.00 . x
ARCH.OR ENG. PERMIT VALIDATION
AODREss SPECIALCIRCUIT -'5.00
ZIP EMP.METER OR POLE INS. - 15.00
ADDRESS rs MOTORS - SEE FEE SCH. V/n11
ADDRESS 1 ,
SERVICE CHANGE _ 10.00 �/1/
0 0 0 - LICENSED CONTRACTORS DECLARATION
r¢U v I hereby affirm that I am licensed under provisions of Chapter t) ANCE DATE
z w (commencingwith Section]000)of Division 3 of the Business and
rA 4 y - - 80. 1ELECT. PLG. MECH.
F w z Professions Cod td my license is in or
full to • an of
o i m =/ Livens lass Lic.NumbeDmv_ i' Ff� F. / ❑ ❑ ❑
a m f • .s BUILDING PERMIT
¢ ¢ w .OWNER-BUILDER DECLARATION INFORMATIQfx
X
;u H I hereby all that I am exempt from the Contractor's License MISC.- - REFER TO ORD 1�--
F u o A Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE" '6.00 VALUATION- $/FT.
Code:Any city or county which requires a permit to construct,alter,I - /}�
¢Q 2O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. - LIC.NO. ELEC. " I V*/ (�
o¢ requires the applicant for such permit to file a signed statement that - TOTAL
u w m a- he is licensed pursuant to the provisions of the Contractor's License *„ • v PERMIT TO -
C z i Law(Chapter 9(commencing with Section 7000)ofDRislon 3 ofthe a` roN, o a v T5 x v v 'v eN�,- yis
¢ o Business and Professions Code)Or that he is exempt therefrom and D.T},Y Twy"'> -,kA P,LUMBI NG?PE RMIT.}„ '$#men-, FEE
¢ r m the basis for the alleged exemption.Any violation of Section]031 S t++, x ;? t'?+•^' TORI S TYPE CONSTR.
d3 _ by any applicant for a permit subjects the applicant too civil Penalty ALTER-DRAIN (EA.)of of more than five hundred dollars($500).): ( r
0 I,as owner of the property,or my employees with wages as� BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.U TS
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
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAPre _ 4.00 SD.F .FLO fl AflE TOTAL ACREAGE
,�. himself or through his own employees:provided that such improve.
.cuts anot intended or offered forsale.If,however,the building GAS-EA.SYSTEM-1 4.00
or improvement is sold within one year or r6ropletion,the owner- GAS-EA.SYSTEM-OVER q IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or int-
' prove for purpose of sale.). - ' ES IND CON PB OxM1ar
❑' 1,as owner of the property,am exclusively cont'nacling with INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑ '•',
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESS ORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply ,
to an owner of properly who builds or improves thereon,and who LAWN SPR INKLERS-OVER 5(EA.) " 1.00 '
contracts for such projects with a conlrac(ods)licensed pursuant to
the Contractor's License law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. ( I PARCEL NO.
.❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00 V
reason
Owner, . Dale - WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION - - WATER TREATING EQUIP. 4.00 '
I hereby affirm fbal l have.certificate ofommenl to sell-insure. - ZONING ENG.SITE NO. '
or.certificate of Workers'Compeen�ssati�onI
� nsur�an,e`c,Or a certified
' PY therjrllJSgy�3 ACompanY 1SQ-+151 ` N/��
Policy N
O' 1 ❑ Certified copy is hereby furnished RE SPRINK ENERGY T-2/
Z
- ❑ Certifie ) is B with ))su� dy Inspection division.
• F- O Applicant � 5'P-f �K� _ MISC- REFER TO ORD. v❑ N❑ ' r,❑ N❑'
toPERMIT ISSUANCE „6.00
CERTIFICATEOF EXEMPTION FROM WORKERS' FLOOD ZONE A.L.U.C.
LU �_ COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
CLO (This section need not be completed if the Permd is Cor one TOTAL V❑ N❑ Y ❑ N❑
Z).Z Immireddoll.,S0100)orless.) ,,,, u' "'.5'R'v
U O'" I certify that in the performance of the work tor'wh¢h this per, Q3 . MECH N Cq`L,PERMIT y FEE FEES M Y
ILL I- mit rs Issued I shall not employ any Person in any manner so as to € v r a: +a kgv§� wev.t
O 0 become subject to the Workers'Compensation Laws of ColiCorma -
u Date-Applicant Applicant 'ALTER OR ADD TO MECH. 4.00 BUILDING 1
} W NOTICE d0 APPLICANT: If,after making this Certificate of Ex- J
Z emption,you should become subject to the Workers'Compensation APPLIANCE' 4.00 PLAN CHECK
provisions of the Labor Code;you must forthwith comply with ' FEE
•5> such provisions or this permit shall be deemed revoked." AIR HANDLING UNIT(TO 10=CF.M.) 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 5.00 . SEISMIC.FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which lhls'permil is issued(Seo. MICROFILM
I 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.
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 -
information is correct. Lagree to comply with all cityand county PLUMBING
ordinances and.slate laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00
hereby authorize representatives of4his city to enter upon the BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-menlmned property far 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 i any way .ccH., against said City in consequence of the
graul ng f This pcnmi MECH.CONT. LIC.NO. - MECH.
TOTAL
p pcanOmim,lor TOT
Signature of ate ALft
OFFICE,COPY