6936 ., APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BU I LDI NG PROJECT I DENTI FICATI ONPERMIT NUMBER
P.ILDING ,APPLICATION & PERMIT
Anne ESS
6936
IV1 JK BUILDING - L'
ELECTRICA —PLUMBING—MECHANICAL
-
�awrvER'a PLAN CHECK VALIDATION
�OMEM l'i'
CITY. - ELECTRIC PERMIT FEE '
1 1 PHONE "l 1
NONEflacroRs UTLETS-SWITCHES-RECEP 5.00/1.00
uc.N LJ LIGHTING FIXTURES 5.00/1.00 '
QE
TRACTOR'S
a s 'APPLIANCES-RESIDENTIAL 4.00
. ,o' F�NEpgy PANELS 5.00 DATE OF APPLICATION
ARCHITECT OR PLAN CHECK FEE P.C.NO.
ENGINEER -
" uc.No. , SIGNS TRANS. 3.00 '
ADDRESSS ENO' SPECIAL CIRCUIT '5.00 PERMIT VALIDATION
ZIP . EMP.METER OR POLE INS. 15.00
ADDRESS -
ADDRESSPP MOTORS SEE FEE SCH.
/
SERVICE CHANGE 10.00
woo LICENSED CONTRACTORS DECLARATION
a'i w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing will Section 7000)of Division 3 of the Business and
BLDG. ELECT. PLG. MECH.
iN i Professions Co n else is in full t ❑ F-1 El
m O Licen 'Gla Lic.Num - - - -
r w Dale_ Conlmct
¢ rc
OWNER-BUILDER DEC AnBUILDING PERMIT
oN ° - INFORMATION
E
;LL y 1 h6mby affirm that I am exempt from the Contractor's License MISC.—' REFER TO ORD
IL o¢ Law for the following reason.(Sec.703 L5,Businessland Professions VALUATION $/FT.'
r - N J PERMIT ISSUANCE 6.00
Code:Any city or county which requiresa permit to construct,alter,
ELEC.CONTR. . LIC.NO:
¢ ¢O improve,demolish,or repair any structure,prior to its issuance,also ELEC.
O u requires the applicant for such permit m file a signed statement that +v, - TOTAL pERMIT T
n w m Ile is licensed pursuant to the provisions of the Contractor's License
F z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
¢ Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢ m the basis for the alleged exemption.An
g p y violation applicant to ofSection malty STORIES TYPE CONBTR.
n3 — by any applicant fora permit subjects the0).) toacivil penalty ALTER-DRAIN -WATER (EA.) 4,00
of not more than five hundred dollars(my em):
❑ Las owner at the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 DCC.GROUP RES.UNITS
inter sole compensation,will(S the work,and Business
structure is nos
'intended of 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 '
property who builds or improves thereon,and who does such work FIXTURES,PER TRAP - 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
� himself or through his own employees,provided that such impfove-
) melts are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 .'
builder will have the burden of proving that he did not build or im- BUILDING USE RES IND CON PB Other
move for purpose of the.). - . INDUSTRIAL WASTE INTER.
❑ I,as owner of the,property;am exclusively contracting with 20'00 .El . ❑ ❑ O ❑ .
licensed contractors 10 const..[ the 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 contractor(s)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,BAP.C.for this
reason WATER HEATER W/VENT 4.00 '
Owner• Date. WATER SYSTEM 4.60 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00 . '
I hereby affirm that I have a certificate ofconsent to self-insure. - ZONING ENG.SITE NO.
or a certificate of Workers'
W�y�yoorkers'Compeyy��atum Iusur c,0r a certified -
copy.lhelSa)jf��+s ah .). / 1�A /
Policy fIAAIII�� l Ytl]
O ❑ Ecrlifi py is hereby l'u Wished. FIRE SPRINK ENERGY T-20
Z Z Cf Cert inyl'� lh the city inspection devise MISC.- '- REFER TO ORD.
O Applicant ll,ad,l Y[3 IN V C] N�
Fy PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
G: CIiR CATS OF EXEMPTION FROM WORKERS'
W > " COMPI7NSAT10N INSURANCE PLG.CONTR. LIC.NO. PLG. `
M. 0 (This section peed not be completed if the permit is Ibr one TOTAL Y❑ N Y 0 N�
Z) Z hundred dollars($100)or less.)
U O 1 certify that in the performance of the work for which this per CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
D- Dam ApplicantALTER OR ADD TO MECH. 4,60 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex- _
F— 2 empsion,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of she Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall.be deemed revoked. AIR HANDLING UNIT(TO 10=41F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.FM.)'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 100,000 B.T.U.)7.50
Lenders Address - - , ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 SII
information is correct. I agree to comply with all city and county .I PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COMP(3H.P.6r 100,000B.T.U.) 4.00 -
hereby authorize representatives,of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for 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 O CONST.TAX
-
wmay in any way acerae against said City in consequence of the
a Gfth's el i i MECH.CONT. LIC.NO. H.
TOTALTOTAL
I tumof Aplicant/Comtrm, r gate P
- I11Vs d1�.p' J //?CC)��1
r FFICE COPY