09838 APPLICANT,TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I.DENTI FICATION I + PERMITNUMBER
BUILDING ZOr4 - - APPLICATION &PERMIT
p;0.97G 'il/iAA L BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 09'838
OWNER'S - + s.; Z PLAN CHECK VALIDATION
NAME PRONES CITY.rk �xdr , ELECTRIC:PERINITA�1 vLy. .y�,FEE¢q
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. ' N°MERAcrofls OUTLETS-SWITCHES-RECEP 10.00/1.00
Alle-5 T6
TCO Y A C.No. LIGHTING FIXTURES 10.00/1.00
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CONTRACTORS
ADDRESS
I APPLIANCES-RESIDENTIAL 4.00
,LIy71V &;� 2l
'
PANELS 10.00 DATE OF APPLICATION
ARCHITECT .. PANELS (OVER"200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENIGINEEfl
' - uc,No. SIGNS TRANS. 3.00 '
noo ESS emc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
. _'IIP EMP.METER OR POLE INS. 20.00 PAAJD
A - - MOTORS SEE FEE SCH.
DRESS Ess
ADOR OCTn Qp
/J'7W e,1V lYWAA!ULIL' SERVICE CHANGE 20.00 CUC-p1985
ctoo ICENSEU CONTRACTORS DE LARATION p TEMP.POLE 30.00 rS ARCE bIn4E�"Ino
¢u w 1 herebyaffirm that I am licensed under provisions of Chapter 9
y ¢ & (commencing with Section 7000)of Division 3 of the Business and - BLOC. ELECT. PLG. MEC -
H H Z Professions Code,and my license is in full for, id f e t�
o 0 m o License Class LIc,Numb•r11 El 0
H y H j Date l0 Contactor ,.
a m ce OWNER-BUILDER DECLARATION }'y Nf BUIL°DINGPERMIT '
° a MISC.- REFER TO ORDi`' IN FORM_ ATIONp
w ; LL N' 1 hereby affirm that I am exempt from the Contractor's License VALUATION
u o¢ Law for the following reason.(Sec.703 LS,Business and Professions $/FT.
� - -I Code.Any city or county which requires.permit to construct,alter, PERMIT ISSUANCE 10.00 ,
¢ 2¢2O improve,demolish,or repair any structure(prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC,
"in u requires the applicant for such permit to file asigned statement that TOTAL E
u w m he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencingwith Section 7000)of Division 3 of ther •- v „. - - - # a t a,8 x
¢ Business and Professions Code)or that he is exempt therefrom and QTV1 �'' ;, PLUMBING PERMIT t y n p "FEEI
E i o mp
¢ r$ the basis for the alleged exemption.Any violation of Section 7031 5 / s + '�' x 53:9 STORIES -TYPE CONSTR.
Ea
by any applicant for u permit subjects the applicant toacivllpennity ALTER-DRAIN -WATER (EA.)� 5.00
o'not more than five hundred dollars($500).)'. -
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE - 4.00 .
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.uNlrs
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or,improves thereon,and who does such work FIXTURES-PER TRAP5.00 SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4'(EA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RE IND CON RE Ot❑he,
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec, 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS FARCE L NO.
and Professions Code:The Contractor's License'Law does not apply
to an owner of property who builds or improves thereon,and who LAWN'SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with z c.mmetor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec..,B.&P.C.for blis
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5,00
- I hereby affirm that 1 have a certificate of consent to self-insure,
or a certificate of Workers Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.). -/
Policy No, - Company /K7
Q ❑ Certified copy is hereby furnished. FIRE$PRINK ENERGY T-24
Z �S. Cert" o�y♦s 0 d wit to uy Ins�eD' 'Glvisn.
F O Applicant ' .Lfa<.T,of jr I e - R,� MISC.-. REFER TO ORD. y[] N� v Q N,[
CC.N CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
UJ > (This section need not beTcomp�AIONlleted Rf,he FPermit is for one PLG.CONTE,ao LIC.N0. TOTAL Y N Y❑, NEI '
D Z hundred dollars($100)or less.)
U•O I certify that h the performance of the work for which this per. OTV: ,' & `-MECHANICAL,PERMIT ' F `t S,' FEE 3 t s I EE-SUMMARY -
LL.1- mit Is issued,I shall'not employ any person in any manner so as to a , _ q,y. 9, F ( a, ,t ,v
U become subject to the Workers'Compensation Laws of California: _
UQ. Date ApplicantACTER'OR ADD TO MECH. 500 BUILDING
,� Be NOTICE TO APPLICANT: If,after making this Certificate of Ex-Z_ emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with F
U such provisions or this permit shall be deemed revoked.,, AIR HANDLING UNIT(TO 10MC.F.M.) 4.00 EE
CONSTRUCTION LENDING.AGENCY AIR HANDLING UNIT(OVER 10,000GEM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.0.). / HEATING UNIT(TO'100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and shite that the above VENTILATION FAN (SINGLE)000 6.00
4.00 -
. information is correct.1 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, B.T.U.)
hereby authorize representatives tto his oths city purposes.enter upon the
above-mentioned property for Inspection BOILER-COMP IOVar.100,000.BTU)SEE FEE SCH. MECHANICAL
es
(We) agreeto 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' '10.00
ranting Of this permit MECH.CONT. ' ,LIC.NO. MECH. ,
.t -`85 TOT - TOTAL; �
Signature a f Applicanto-o rector Date r
•
OFFICE COPY
I