6279 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER euiLowc APPLICATION & PERMIT
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A�OE%�3 G L_of,-e`( 1�LL,�.S G Vy
O Lp{ BUILDING-ELECTRICAL-PLUMBING-MECHANICAL IV'
OWNER'S
NAME
PLANCH VALIDATION
awn�� .A QTV:f �" r'tEL'�ECTRICdPERMIT$ s�`Z.' ' FEE i iU /��3.�//
nYa-o'1sm PHONE
U11�
CONTRACTORS
NAME UTLETS-SWITCHES RECEP 5.00/1.00 V
050 ��C7-uP6R.S 3 flq S LIGHTING FIXTURES. 5.00/1.00 f /a/Y •��
C.NO
CONTRACTOR
SAl PHONE n-^7 PPLIANCES-RESIDENTIAL 4.00
37 Ao^ofREes�s �k, , y� -0l dol
f) Av�• PANELS 6.00 . DATE OF APPLICATION
ARCHITECT t SIGN$ 600 PLAN CHECK FEE P.C.NO.
ENCINEEsrOSO O C�t'�. L' �.� �� SIGNSTRANS. 3.00
LIC.NO
ARC"OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
xStA't:C SS
ZIP EMP.METER OR POLE INS. 15.00
ADDRESS MOTORS SEE FEE SCH.
SWw.L SERVICE CHANGE 10.00
w o o LICENSED CONTRACTORS DECLARATION
a u U I hereby affirm that I am licensed under provisions of Chapter 9 0�4 ISSUANCE DATE
m z w (commencing with Section 7000)of Division 3 of the Business anJ _ BLDG. ELECT. PLG. MECH.
D m Professions CodL I license is in full for'•pn�Ly.(Po ❑ ❑ ❑
z Z" License C as_s R_�\L Lic.Numberl0_�17![ 0
s-w Date/ Contractor-O,S
a Y f '. / ERMIT,
¢ O a O OWNER-BUILDER DECLARATION - a INFORMA,TjION -
w ;w N I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD I }) 0 VACUATION S/FT.
Fw0¢ Law For the followtngreason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6,00
vs Cade:Any city or county which requires a permit to construct,
¢¢ improve,demolish•or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. /S
O 1requires the applicant for such permit to Me a signed statement that TOTAL PERMIT TO
war Se he Is licensed pursuant to the provisions of the Contractor's License
'Law(Chapter 9(commencing with Section 7000)of Division 3 of the v. _
E i 0 Business and Professions Code)or that he Is exempt therefrom and QTV.'j ' .'PLUMBING-PERMIT. "FE-�+'1•'
¢ F$ the basis for the alleged exemption.Any violation of Section 7031.5 ""'i - STORIES TYPE CONSTR.
UP by any applicant for a permit subjects the applicantto a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than Ove hundred dollars(S500)J:
❑ I,as owner of the property,or my employees with wages as BACK FLOW 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,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 are-not
ngh tende owaemred for Sale.
If,ed that however,
the
improve- GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
me nts are not intended or offered for sale.Icompleveq[he building
or improvement isSoldb within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
Prove f will have the burden of proving that he did not build or ins- - RES IND CON PB Omer
Prove 1,as pose of the
- INDUSTRIAL WASTE INTER. 20.00
O 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC.5'V.B. 5.00 ASSESSORSPARCEL NO.
and ProfessionS Code:The Contractors License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 r
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWERSANITARY-STORM EA.20OW8.00 TRACT NO, PARCEL NO.
❑ 1 a exempt under Scc. ,B.&P.C.for this WATER HEATER W/VENT 4.00
inn
Owner Data WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPF NSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent lO self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified _
copy thereof ISec. 800,Lab C..
Policy No2W�iy/Company.�QQs�1{��DFC.-�
U ❑ Can't'ed copy*,hereby furnished. FIRE SPRINK ENERGY T-Z4
z Z ❑ Ce1.1 1 Iled witl the city inspection division. MISC.- REFER TO ORD.
Ariplicnnl V❑ N❑ Y ❑ N❑
K y CEKTI FICA'fli0 :XIiMPTION FROM WORKI?RS• PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.c.
LU >_ I COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
n- O (This section need not he completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
0 Z hundred dollars(5100)or fuss.)
U O 1 certify that in the performance of the work for which this per, QTV; v. +' MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued.I shall not employ any person in any manner so as to
U become subject to the Workers Compensation Laws of California.
O w pate Applicata I BUILDING
o, Y ALTER OR ADD TO MECH. 4.00 9.Z.;
} N NOTICE TO APPLICANT': If,after making this Certificate of Ex-
F Z mnption,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 such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10A00C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IO,000C.RM.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the perfommnce 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 HEATINGUNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I have read this application and slate 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 construclion, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE F EE 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 3.001 CONST.TAX
in in any s'ay a e against id City in Consequence of the
It
m MECH:CONT. -'LIC.NO MECH. c�
dD $tr _ TOTAL TOTAL !3
Sig lire of Applican ontractor are
I
OFFICE COPY