4404 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDING PROJECT IDENTIFICATION P RMIT NUMBER
a°ILnINa. y APPLICATION & PERMIT 4404
ADDRESS ��J 4 l ��
Z bit E BUILDING-ELECTRICAL-PLUMBING-MECHANICAL -
OwNEO'S - PLAN CHECK VALIDATION
NAM QTY. ELECTRIC PERMIT FEE
q PHOrvE
NAMERAcraR se'l eV ys �� /Cd n- .'J�9 UTLETS-SWITCH ES c'R ECEP . 5.00/1.00
C Z LIc.No: LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S fPPLIANCES-RESIDENTIAL 4.00
ADDRESS J
3 ,> /ggoNE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.ND.
OR
ENGWEER
LIC.NO. SIGNSTRANS. 3.00
moo esu ENG SPECIAL CIRCUIT - 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00 ��
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
t SE ICE CHANGE 10.00
Oo LICENSED CONTRACTORS DECLARATION I0y l - PAID'
a Z w I hereby affirm that I am licensed under provisions of Chapter 9 0-I F(3 ISSUANCE DATE
¢ e, (commencing with Section 7000)of Division 3 of the Business and BLDG ELECT. PLG. MECH.
O i Professions Co and- •%I'cense is in full for a •fkek
z O H.. License Class _ Lic.Number - b ,� ❑ ❑
i. 9 y g Dale Lie.N . `Q
¢ ¢ W ¢ OWNER-BUILDER DECLARATION BUILDINGPERMIT
oa " MISC.- REFER TO ORDC't 0 U
X ; H 1 hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
o a Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 6.00
5 y�� Code:Any city or county which m quiresa permit to construct,alter, ELEC.CONTR. LIC.NO.`
¢ 5 ¢O improve,demolish,or repair any structure,prior tD its issuance,also ELEC.
0 LL requires the applicant for such permit to file a signed statement that TOTAL. PERMIT TO
w $m he is licensed pursuant to the provisions ol'the Contractor's License
H,2> Law(Chapter 9(commencing with Section 7000)o(Division 3 ofthe 6 La
¢ Business and Professions Code)or that he isexempl therefrom and OTY. PLUMBING PERMIT FEE �F
IS O the basis for the alleged exemption.Any violation of Section 7031.5 ^^'-STORIES TYPE CONSTR.
La ;$ by any applicant for a permit subjects the applicant to a civil penalty N Ad J /N b'
of not more than five hundred dollars(5500).): ALTER-DRAIN&VENT-WATER (EA.) 4.D0 P
❑ I,•as owner of the property,or my employees with wages as BACKFLOW PROTECT.DEVICE 2,00 OCC.GROUP REB.UNITS
their sole compensation,will d0 the work,and the structure is no[
intended or 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 mf
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 50.FT,FLOOR AREA TOTAL ACREAGE
himself or,through his own employees,provided that such improve-
s� meats are not intended or offered for sale.If,however,the budding GAS-EA.SYSTEM-11NC.40UTLETS 4,00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
-
builder will have the burden of proving that h - .e did not build or am- - RES IND CON PB Omar
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
O I,as owner of the properly,am exclusively contracting with ❑ El 13 1:1 1:1
licensed contractors to construct the project(See. 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 contractorfs)licensed Pursuant to -
theContractor'sLicenseLaw. SEWER-SANITARY-STORM EA.200f1/8.00 TRACT NO, PARCELNO.
❑ lam exempt under Sec.-,BL&P,C.for this WATER HEATER W/VENT 4.00
reason
Dale Owner WATER SYSTEM 4,00ACC.DATE ACC,FILE NO.
WORK Ii RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00 -
1 hereby affirm that I have a certificate of corse t to self-insure, 20NING ENG.SITE NO,
or a certificate of Workers'Compensation Insurance,or a certified
copy thet+e,
Policy N/p ec. 0 abmy C.). �•
� '(•f?.l-i--[-w_^P
Q ❑ Certified copy is hereby furnished 'FIRE SPRINK ENERGY T 24
Z B�Cert' it co y 1s 11 with he city inspecli�/d ' 'rh. -
Applican `-sus/� Cio /1/71[- MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
~ m - T- PERMIT ISSUANCE 6.00 FLOOD ZONE - A.L.UC.
CC CERT1171CATE OF,EXEMPTION FROM WORKERS'
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL 0 (This section need not be completed if the permit is for one - TOTAL Y❑ N Y❑ N❑' .
Z) 2 hundred dollars(S 100)or less.)
U O 1 certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL f- mit is issued,.)shall not employ any person in any manner so as to
Qw become subject to the Workers'Compensation Laws of California. BUILDING
y Date-Applicant ALTER OR ADD TO MECH. 4.00 -
} Va NOTICE TO APPLICANT: If,after making this Certificate of lix.
F 2 emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you mus[ forthwith comply with FEE
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1Q000OF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 10=C.F.M.15.00 SEISMIC FEE 0
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. HEATING UNIT(TO 100,000 B.T.U.) -4.00 MICROFILM
3097,Civ.C.).
Lender's Name HEATI NG UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
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.1 4.00
hereby au[IlOrilC representatives of this city to enter upon [he BOILER-COMP(Over 100,000 STU)SEE FEESCH. 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 CONST.TAX
may in,any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00 _
gran[ihlk pf[ per(t/ryry11` ,9 MECH.CONT. - LIC.NO. MOTECAL
H. TOTAL /
4. TQ
. � �pnalure of APPI¢anl/Con[raaor Dale r '
OFFICE COPY