3921APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT 1 DENTI FICATI ON
APPLICATION & PERMIT
BUILDING -ELECTRICAL -PLUMBING -MECHANICAL
ERMIT NUMBER
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( I
PLAN CHECK VALIDATION
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ELECTRIC PERMIT FEE
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CONTRACTORS `ZB333v
N
OUTLETS -SWITCHES-RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
;ME
TIBC ua rvo.
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.
DATE OF APPLICATION
CONTRACTORS
ADDRESS
ooRFs� �,-r7-'7g
Vs -5• JP_7&SjU ONE
APPLIANCES - RESIDENTIAL 4.00
PANELS 5.00
ARCHITECT - -
OR
ENGINEER
uc. NO
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
,
SIGNS TRANS. - 3.00
ADDRESS eNG. Y
SPECIAL CIRCUIT 5.00
P///E111RM.IT/VALIDATION
TEMP. METER OR POL 15.00
nv
AADDRCEESSDDRSS
MOTORS' SEE FEE SCH.PPLI
SERVICE CHANG �UG10.00
0
O
LICENSED CONTRACTORS DECLARATION
E4Z7- d O+
I hereby affirm that 1 am licensed under provisions of Chapter 9
(commenting with Section 7000)mf Division 3 of the Business and
Professions Co t license is in full f a •yam..
Li,an sc a s Lic. Number ,[=
E DATE
BLDG, PLG. MECH.
Ex
Dme Contractor ARS _v_
WNE -BUILDER DECLARATION
I hereby affrm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Business and Professions Code:
Code: Anycity urcounty which requires a permit construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter9(commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
IGING PERMIT
INFORMATION
MISC. - REFER TO ORD
,/O 006
%
ISSUANCE 6.00 b .-.
ELEC. CONTR. LIC. NO. -
ELEC. V NA
TOTAL `
PERMIT TO
��]
tS L!l //`r1/-7' ^`F - AOL
CITY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Seclion7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars ($5001.).
ALTER -DRAIN& VENT -WATER (EA.) 4.00
❑ 1, as owner of the property,.or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE - 2,00
DCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
intended or offered for sale (Sec. 7044, Business and Professions
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 improve-
ments are not intended oroffered for sale. If, however, the building
GAS - EA. SYSTEM -1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or int-
prove for purpose of sale.).
I, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 1.00
BUILDING USE
RES INDCON PB Othe,
[:] E] E]❑ E]❑
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - O .) 1.00
ASSESSORS PARCEL NO.
licensed contractors to construct the project (Sec 7044, Business
and Professions Code The Contractor's License Law does not apply
to an owner of property who builds or improves thereon. and who
contracts for such projects with o conhuctorfsI licensed pursuant rn
the Contractor's License Law.
SEWER-SANITARY-STO .200ft/B.00
TRACT NO.
PARCEL NO.
❑ 1 am exempt under Sec. BAP.C. for this
reasan1PO
WATER HEATER W/VENT .00
-
Dam Owner
WATER SYSTEM 4.00
ACC, DATF
ACC. FILE NO.
WATER TREATING
WORKERS -COMPENSATION DECLARATION
I hereby affirm that 1 have a certificate of consent to self -insure,
or a certificate of Workers' Compensation Insn' te, or a certified
c oScp(,fLaK ,any 11 J-pL �
Policy licy NrdJ-7 > Ip EVI YC'120
❑ Certified copy is It vacby furnished.
❑ CerufieJ-oplyi etc w I the en division.
Applicant _-/2r -
ZONING
ENG. SITE NO.
OP L, -
FIRE SPRINK
Y ❑ N ❑
ENERGY T-74
Y ❑ N❑
MISC.- REFER TO ORD.
CHRTIFICA'rE OF EXGf71-ION FROM WORKERS'
PERMIT ISSUANCE 6,00 & Ol-
FLOOD ZONE
A.L.U.C.
PLG. CONTR. LIC. NO.PLG.
TOTAL �EP
COMPENSATION INSURANCE
(This section need. not be completed if the permit is for one
Y ❑ N❑
Y ❑ - N❑
CITY. MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars IS 100) Dr less.)
. I certify that in the performance ol'the work for which this per-
mil is issued, I shall not employ any person in any manner so as to
BUILDING
��% ..�l.
become subject to the Workeri Compensation Laws of California.
Date - Appletat
NOTICE TO.APPLICANT:,If, after making this Certificate of 1>x-
ALTER OR ADD TO MECH. 4.00
APPLIANCE 4:00
PLAN CHECK
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10p00C.F.M.) 3.00
AIR HANDLING UNIT (OVER 1000C.F.M.) 5.00
SEISMIC FEE
0
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, CN.C.).
Lender's Name
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UN IT(OVE B.T.U.)7.50
ELECTRIC
020
Lender's Address
I certify )har I have road this application and state that rhe above
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
VENTILATION FAM 3.00
PLUMBING
'
.-
BOILER-COMP(3 .P. 1 ,00 ) 4.00
BOILER -COMP 1 ,a BTU SEE FEE SCH.
MECHANICAL
GAa
MISC. - ORD.
PERMIT ISSUANC 3,00 ..'� _
CONST. TAX
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, c s ayd expenses which
may in any way accrue against sai try, n con se uc/}p�cey the
ting of thi ¢ it. / /��
MECH. CONT. LIC. NO. -
TOTAL QJ
71
TOTAL
K.3 Z/
Signuture of pplicant Contruclor Dare '
OFFICE COPY