9391 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALLPOINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS QD�8 1 V UILDING - ELECTRICAL-PLUMBING-MECHANICAL .r.; 939 1
OWNER'S - -
NAME1 / AAI3 atS-' a Y.fikt 4p x*,@ '} -` PLAN CHECK VALIDATION
OTV2 < 31 .ELECTRIC PERMIT _ ?. T' kFEEf
Y
RAcroRsAu 00N
uc NO LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
ADDRESS army✓ G YIPP APPLIANCES-RESIDENTIAL 4.00ArA
S ^
a aw -'be PHONE 73'y MOO PANELS - 10.00
. DATE OF APPLICATION
ORcwiEDT - PANEL$.IOVER 200 AMP) 20.00 PLAN CHECK FEE P.O.NO.
ENGINEER
- LIC.NO, SIGNS TRANS. 3.00 '
ARCH.OR ENG, PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00 ,.y
ZIP EMP.METER OR POLE INS. " 20.00 Pq1,�
APPLICANT'S
ADDREss / ,\ MOTORS � SEE FEE SCH. .�
/YG LUOod U GGy7,7 V Va- ISERVICE CHANGE 20.00
02 LICENSED CONTRACTORS DECLARAT16fs TEMP.POLE _ 30.00 OCT 11 1985
a v o 1 hereby affirm that 1 am licensed under provisions oh Chapter 9 '
2 in ISSUANCE GATE
(commendng with Section 7000)of Division 3 of the Businessland w i Professions Code and n Ilce Ise is in full fore of L ^ BLD E C pEf MECH.
z i m D License Class-d'� Lic.Number ❑ O
9 Date' Contractor ,� F j
m r '
El F
o at 4 - OWNER-BUILDER DECLARATION $ x A BUI 'DING,PERMIT'x?a'
X ;u. r I hereby affirm that I am exempt from the Contractor's License x`g g d INFORINATIONf
MISC.- REFER TO ORD .
u O¢ Law for the following reason.(SIC.7031.5,Businessand Professions - VALUATION $/FT.
Code:An Cil or count PERMIT ISSUANCE 10.00
2 anw i Y Y y which requires permit it to wnsuanc ,also E
Q O improve,demolish,Dr repair any fracture,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
IS
requires the applicant for such permit to file a signed statement that X300 9' TOTAL•
n w m he is licensed pursuant to the provisions of the Contractor's License a PE MIT TO -
> Law(Chapter 9(commencing with Section 7000)of Division 3 of the - 6 h ' a - '" ,t 4 v I
io Business and Professions Code)or that he is exempt therefrom and DTV". .PLUMBING'PERMIT t a E T FEE- I
IS
E$ the basis for the alleged exemption.Any violation of Section 7031 5 ,,v 8 '' 4 $) aT'j STORIESTYPE CONSTR.
P
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN'&VENT-WATER (EA'S 5.00 '
of not more than five hundred dollars($500t): `
❑ 1,as owner of the property,or myemployeeswith wages as BACK FLOW PROTECT.DEVICE' 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered I'or sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 -
Code. The Contractors License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
memsarenotintendedorofferedforSaW,If,however,the building GAS-EA.SYSTEM-i INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or im. GAS-EA.,SYSTEM-OVER 4 (EA.) 2.00 BUILDING.USE
prove for 1,aso of sale.). INDUSTRIAL WASTE INTER. 30.00 ES 1❑ ❑N ❑ other❑
❑ I,as ownernee of the property,ran exclusively contracting.wilh
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 -
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.210.00TRACT NO. PARCEL NO.
❑ 1 a exempt under Sec. ,B.&Y.C.lorthis
reason WATER HEATER W/VENT 6.00
Owner Data _ WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 _
hereby affirm that I have a certificate of consent to self-Ireure,
or a certificate of Workers'Compensation Insurance,or a Cerfil led ZONING ENG.SITE NO.
copy the 4lSc Op g4 f!
Policy N o ($rhQf
O ❑ Certified Copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z •Cert ifie 9p is f with j1 city inspection division.
PO Applicant g �/�"Ti'Ire MISC.- REFER TO ORD. Y [:] "NC] v0 No
N CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W COMPENSATION INSURANCE - PLG.CONTR. LIC.NO. PLG.
CL O (This section need "not be colopleted if the permit is for one TOTAL Y❑ NEI Y 0 NE]
::) Z hundred dollars($100)or less.)' "
p . a ;s y s% ,FEE SUMMARV3k * '
U O 1 certify that in the performance of the work for which this per- OTV a- • MECHANICAL`PERMIT,a .'"FEE
IL 1- mit is issued,I shall not employ any person in any manner so as to q x
U becomesubject to the Workers'Compensa tion Laws of California. tr ` - a
y Date Applicant ALTER OR ADD TO MECH. 4 5.00 _ BUILDING H .
} 2 NOTICE.TO APPLICANT: If,after making this Certificate WET -
f- _ 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 panni[shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IO,OODQRM.) 6.00 SEISMIC FEE
1 hereby 5lfirvi that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
rte performance of the workfor which this permit Is issued(Sec. MICROFILM
3097,Civ.C.L _ 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 state that the above VENTILATION FAN (SINGLE) 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 100,000 B.T.U.) 6.00
hereby authorize representatives,of this city to enter upon the gO1LER•COMP.IOvar 100,1100 BTU)SEE FEE SCH.
above-mentioned property for inspection purposes. MECHANICAL
(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 10.00
gran' gof thispe..t may/ MECH.CONT. LIC.NO, - MECH. -
J /.a '�I��S' TOTAL .
Signature of Applo Contractor .Date `
TOTAL'
OFFICE COPY