6558 APPLICANT TO FILL IN.INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
' BUI LDI NG PROJECT I DENTI FICATION, PERMIT NUMBER
3WIDING APPLICATION & PERMIT ^'�
ADDRESS
OOREss Ivy
O Oo WI Ck p BUILDING'—ELECTRICAL—PLUMBING'—MECHANICAL
Ow
ER's - - PLAN CHECK VALIDATION
• L NAME G / HONE,(J.J�'{(^[_ OTY. ELECTRIC PERMIT FEE
F, r/.4 P '
CONTRACTOR_ft 'S
❑f
Is UTLETS-SWITCHES-RECEP 5.00/1.00
�Q-r 7749 aV6 LIC.No LIGHTING FIXTURES 5.00/1.00
CONTRACTOR
A I�REss (;f</rOY APPLIANCES RESIDENTIAL 4.00
p[ b �A, PHONE PANELS 5.00 DATE OF APPLICATION
ORHCHITECT SIGNS ' 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS.. 3.00
ARCH.OR ENG. - - PERMIT VALIDATION
ADDRESS SPECIALCIRCUIT 5.00
ZIP ITEMP.METER OR POLE INS. 15.00 '
APPLICANT'$
ADDRESS MOTORSCE CHANGE SEE FEE SCH.
r SERVI10.00
X
O ' LICENSED CONTRACTORS DECLARATION /
< u u I hereby affirm that I am licensed under provisions of Chapter 9 ..
y a w (commencing with Section 7000)of Division 3 of the Business and ISSUANCE DATE
r Is` Professions Code and license is in(all fo a nd-�f L ( V� � BLDG. ELECT. PLG. MECH.
zo i w o License Class Lie Lie.Number
m H DateL� Contractor
¢ yE
a a w u OWNER-BUILDER DECLARATION BUILDING PERMIT
MISC.— REFER TO ORD INFORMATION
W'3 LL y I hereby affirm that 1 am exempt from the Contractor's License "'
u o ¢ Law for the following mason.(Sec.7031.5,Business and Professions ATION $/FT.
F - Code:Any city or county,which requires permit to construct,alter, PERMIT ISSUANCE 6.00
K ¢ 00 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO, ELEC.
O LL requires the applicant for such permit to file a signed statement that TOTAL MIT TO
A w m he is licensed pursuant to the provisions of the Contractor's License
Fz.Q
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 OTY. PLUMBING PERMIT Fqq
r m the basis for the alleged exemption.Any violation of Section 7031.5 .T�Y//PE CONSTR.
A � � by any applicant for a permit subjects the'applicant to a civil penalty ALTER-DRAIN 9✓y /F'�4/'t&
of not more than five hundred dollars(8500).): //
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 Occ.GRq�{P
their sole compensation,will do the work,and the structure is not RES.UNITSv
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 Pqq 'd
m
Code:The Contractor's Law does not apply to on 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 improve- - -
memsarenotintended..,offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4,00
'tir improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) ' 1.00 BUILDING.USE
builder will[lave.the burden of proving that he did not build or im-
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 RES 'IND CON PB Other
11 I,as owner of the property„am exclusively contracting with - O
licensed contractors to construct 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 F-
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 emmo t.D0 licensed pursuant to
the Contractor's License Law. - SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this 4 00 Y
reason WATER HEATER W/VENT
Owner - Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
I WORKERS'COMPENSAT ION DECLARATION WATER TREATING EQUIP, 4.00 '
I hereby affirm that 1 have a certi0<aleofconsent to selhinsure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab CJ.�T, ^
Policy No. , Company tEr�[r1e, r of,�_
O ❑ Ce,tifiedcopyiShemhyfD'@ FIRE SPEINK„ ENERGY LI4
Z Z, ❑ Cert ifie'�d�}}ropy is filed w�y/'th�0a city inspection division. ”
FOT AnPlicunl_(�(JI��—Y bB misc.- REFER TO ORD, p[:] IS LJ Y ❑ N[]
Ir h CF.RTIFICA'I'E OF I!XEMPTION FROM WORKERS' . PERMIT ISSUANCE 6.00 FLOOD ZONE A.C.U.C.
'Lu > COMPENSATION INSURANCE: PLG.CONTE, LIC.NO. - PLG.
O (This section need not he completed if the permit is for one - TOTAL - Y NE] Y❑' No
Z hundred dollars(8100)or Ie..) -
L) O I certify that in the performance of the work for which this per, OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil is issued,I shall not employ any person in any manner so as to
O W. become subject to the Workers'Compensation Laws.f California.
y Datc Applicant _ ALTER OR ADD T M BUILDING
} 0 NOTICE TO APPLICANT. If,after making this Certificate of F:x- O MECH. 4.00 /-�
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 4,00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with -
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M) 3,00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MCF.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 -
Lenders Name - •
Lender's Address HEATI NG UNIT(OV ER 100,000 B.T.U.)7.50 ELECTRIC
I certify that l have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00 PLUMBING
,ordinances and'state laws relating to building construction, and
hereby authorize.representatives of this city to enter upon the BOILER-COMP
above-mentioned property for inspection purposes. (Over 100,000 RTUI SEE FEE SCN. 'MECHANICAL.
(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 CONST.TAX
jy
in y way accrue agai taiitCityin consequence of the 3,00n[I f this permit / K.V�/ ffJ MECH.CONT. LIGNO. MECH.TOTAL TOTAL
/Xn I Applicant/Contractor .Dale' • '
OFFICECOPV'