6153 APPLICANT TO FILL IN INFORMATION WITHIN,REDLINES - USE BALL POINT PEN ONLY
-BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
eO,LDING APPLICATION & PERMIT
0liaa oo ,c�CJa, S . .� f _ _ _ 6153
ILDING-,ELECTRICAL-PLUMBING-MECHANICAL
OW S
ry • '' � PLAN CHECK VALIDATION
.G •{C • ''qq G-C1S QTY. ELECTRIC PERMIT FEE
PHONEGQG�
CONTRACTOR'S
OUTLETS-SWITCHES-RECEP 5.00/1.00
LIGHTINGFIXTURES 5.00/1.00
CONTRACTOR'S
ADDRESS '$1rr P,PLIANCES-RESIDENTIAL 4.00
PHONE /-O' T PANELS 5.00 DATE OF APPLICATION
OgCHITECT SIGNS, ,, 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
L,c.NO, _ SIGNS TRANS:,,,, 3.00
ADDRESS ErvG' SPECIAL CIRCUIT - 5.00 PERMIT VALIDATION
ZIP TEMP.` OR POLE INS. 15.00
APPOCANTS MOTORS /..
ADDRESS . . SEE FEE SCH.
J'
CJ /-
SERVICE CHANGE 10.00 . J�liC�
O o LICENSED CONTRACTORS DECLARATION _ 101 J'0
rt w
rt U 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y G m (commencing with Section 7000)of Division 3 of the Business and , LDG. hEL CT. PLG. MECH.
H y Z Professions Code,,yid my license is In full force a f /� � � -❑
z 0„s License Class p'/ Lie.Number 390 T
O Z L .
Dule �Qb-- S
r m L J Contractor <_ a r�(�yy04
a , f+p BUJ ING PERMIT
rc M4 OWNER-BUILDER DECLARATION " - J V U
o w U - INFORMATION
E
3 N I hereby affirm that I am exempt from the Contractor's License ' MISC.-' REFER TO ORD
u o j Law for the following reason.(Sec.7031.5,Business and Pm(essions VALUATION $/FT.
- g PERMIT ISSUANCE 6.00
Code:Any city or county which requiresapermit to construct,alter, - (7(,
o improve,demolish,or repair any stmct me,prior to its issuance,also ELEC.CONTR. _ LIC.NO. ELEC.
/-/ v
O u requires the applicant for such permit to file u signed statement that,
TOTAL '/ PERMIT TO
n w he is licensed pursuant to the provisions of the Contractor's License Nf11h H//}TC3TA./4 C.�
HZi
Law(Chapter 9(commencing with Section 7000)of Division 3 of the `
4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE s7wQ.?-B - of el
F e the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ';m by any applicant for a permit subjects the applicant tea civil penally ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars($5000.):
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
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,GOND. 4.00
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 TRAP 4.00 so.Pi.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such improve-
oruppientroveme not bended or withinrone year are.lcompletinthe the o nor- GAS-EA.SYSTEM-I1NC.40UTLETS 4.00
or lder vement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im RES IND CON PB Other
prove for purpose of sale.). h INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ '❑ ❑ ❑
❑ d as owner of the property,am exclusively, 7044,Bu with
licensed contractors m construct tire project(Sec, 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 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 contractots)licensed refund to -
theContractor'sLicenseLaw, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I inn exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT - - 4.00
reason
Owner Date .SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKP-RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I 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,Lab C.). r-
Policy N.. Company C D W -
❑ Cetifhed copy ishereby famished. FIRE SPRINK C ENERGY T.24
Z
❑ Certified o s ked w'tp the ty ins clion division.
Applicant ` c 1`�BISD a G. - MISC.- REFER TO ORD. v ❑ NO v ❑ No
y CERTIFICATE OF EXEMPTION FROM WORKERS. PERMIT ISSUANCE" 6.00 FLOOD ZONE A.L U,C.
W COMPENSATION INSURANCE: PLG.CONTR. LIC.No. PLG. '
CL Z( This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N
hundred dollars($100)or less.) •"
U'O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I. mil is issued,I shall not employ any person in any manner,so as to
O W become subject to the Workers'Compensation Laws of California.
y Dale Applicant - BUILDING / [ 0
>_ Us NOTICE,TO APPLICANT: If,after making this Certificale of Ex- ALTER OR ADD TO MECH. 4.00 /,2d
? 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
U sucih provisions Or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10PWC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 - SEISMIC FEE
I hereby affirm that there 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.P.50
Lender's Address ELECTRIC
I certify that 1 have read this apphiculion and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct.I 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.) 4.00
hereby authorize representatives necfthis city to enter upon the
inspection above-mentioned property forBOI LER-COMP tor 100,000 BTUj SEE FEE SCH. MECHANICAL
hipurposes. ye
(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 an way accrue egai ost'sa City in consequence of the
gran[ingo sp�Iu1. MECH.CONT. - LIC.NO. MECH.
/l 4yf+wZlsGG �H TOTAL TOTAL /Olaf 74
Slgnatu a of Applicant�Con ctor Date '
OFFICE COPY