09837 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES'-'USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION ,' PERMIT NUMBER
ADDRESS 7- APPLICATION & PERMIT 098.37
ADDRESS
6 BUILDING-EL'ECTRICAL-PLUMBING-MECHANICAL
�. OWNNAMER'S .tY 3i� £ "F N'#, 'f y a t .N a "`
d g PLAN CHECK VALIDATION
/'' 1 '^,r� -•T QTY.e e § e } x ^ LECTRIC�PERMIT , ) x 't n FEEp
1 46&) �1,,"D W/Y�. PHONE
NAMERAcroRs 'OUTLETS-SWITCHES-RECEP 10.00/100
�T� T •14 A' 1 :No.,3 !,G LIGHTING FIXTURES 10.00/1.00
DDRRAcroR's
ADDRESS APPLIANCES-RESIDENTIAL 4.00
A
r 6615Ve-W PANELS 10.00 DATE OF APPLICATION
ORCHITECT PANELS (OVER 200 AMP) 20.00 - PLAN CHECK FEE 'Poco No.
ENGINEER_
LIC.NO. - SIGNS TRANS: 3.00
ADDR'ESSs ENc. .• SPECIAL CIRCUIT -5.00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS- 20.00
APPLICANT'S MOTORS SEE FEE SCH. PA1
ADDRESS
\J CrP-/ST1GN LANG' G SERVICECHANGE 20.00 OCT (J 1J,xJ
00 /X LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 J `,�fJ
¢ u u rl IT
affirm that I am licensed under provisions of Chapter 9IASAWAINCE DATE
h ¢w (commencing with Section 7000)of Division 3 of the Business and BLDG. EL C M
b m z Professions Code,and my license is in full force and
i0 - License L=assp--per' Lic.Nwn
O Z'H w Data/D r•+_ Contmetor
F N J
M m ¢ st OWNER-BUILDER DECLARATION Y y ggBU,ILDINGjP.ERMIT
o a 0 + . - ,y,a*%JINFORIuIAT,'
w1 hereby affirm that I.am exempt from the Contractor's License MISC.-, - REFER TO ORD
LL-O¢ Law for the following reason(Sec.7031.5,Business and Professions VALUATION $/ T.
- J g PERMIT ISSUANCE - 10.00
Code:Any city.,county which requires a pormit to constrnet;alter,
Q'a p improve,demolish,or repair any structGo,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
C K requires the applicant for such permit to file a signed statement that TOTAL
w'$ he is licensed pursuant to the provisions of the Contractor's License E MIT TO
F, zr Law(Chapter 9(commencing with Section 7000)oCDlvlsioa 3 ofthe
g i o Business and Professions Code)or that he is exempt therefrom and QTY.` - "PLUMBING PERMITx x k v t a t'FEE s,
¢ h$ the basis for the alleged exemption.Any violation of Section 7031 5 STORIES TYPE CONSTR.
a S.- by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).): -
❑ I,as owner tireproperty,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4,00 ,
their sole compensation,will the work,and the structure Is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 -
Code:The Contractors License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5,00 -SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve
-
mentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 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 IND CON PB Other
❑ 1,as owner of the property,am exclusively contracting with. -
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 00 AssESSDR 3PARCEL NO.
and Professions Code:The Contractor's License Law dues not apply V.B.. .
to an owner of property who builds or improves thereon,and who _LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contmclorls)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 FACT NO. PARCEL NO.
❑ Iain exempt under Sec. ,B.&P.C.for this
'reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM L 5.00
ACC.DATE ACG FILE No.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I 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,L'ah.0 I
- .O Policy No. Company
rtified copy is herchy furnish d.��0 `,p/ - FIRESPRINK ENERGY T-74
Z Z 'J Cel ifi• coy ❑ d with th' city inspetiold division.
F- p Applicant MISC.- REFER TO ORD. Y.� N Q Y Q N[]
= = 'RTIFICATEi OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE - 10.00 FLOOD ZONE A.L.U.C."
'UJ > COMPENSATION INSURANCE .
PLO,CONTE, LIC.NO. PLG.
CL O" (This section need net m
be completed if the permit N for one TOTAL Y❑ N❑ V❑ NEI
-:)'Z hundred dollars($100).,less.) ^' -
V O 1 certify that in the performance of the work for which this per- _ - "., t i "" a% t d 7
LL"H mil is issued,1 shall not employ any parson in any manner so to CITY.k '' �, a M ECHANR*L,PERMIyT., o- h tis b 'FEE s FEE SUMMARY.ik
. - y
O w become subject to the Workers'Compensation Laws of California. {- - > a a f 3 'b ..t ¢L x f 4 i}
a Dale Applicant - ALTERORADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 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 lO=C.F-M.) '400
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=Q RM.) 6.00 SEISMICFEE
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.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATI NG UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information d correct. 1 agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
Ludirmuccasformatio and stale laws relating to building construction, and
hereby authorize representatives ec this city to enter upon the BOILER-COMP(0ver 100,000BTU1 SEE FEE SCH. MECHANICAL
above-mentioned property forinsp of
purposes. .
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which ' CONSTTAX -
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 -'CONST.TAX
ranting of this permit. MECH.CONT. LIC.NO. MECH. 4
/0�9._ TDTA i / 'TOTAL /
Signature ol Applicant c o actor Date ' I v V
OFFICE COPY - -