3997 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
APPLICATION & PERMIT
9UILDING
ADDRESS
u k`, UILDING-ELECTRICAL-PLUMBING-MECHANICAL 3997
NANER'3 .�.-'' v'%'•: i- 1'- zlti%�M,'Ld, F'J�"a �,�.�_7 A CHECK VALIDATION
NAME DTV. .-'ELECTRIC PERMIT' 4 - ' �'<J
• C)r e ONE
PH3 r/. . N, _
corvrRScroas
NUTLETS-SWITCHES-RECEP 5.00/1.00 +
PME
1 LIC.ND. 7. LIGHTING FIXTURES 5.00I1.00
ADDRESSTOR's
ADDRESS PPLIANCES-RESIDENTIAL 4.00
CONTRA
D)IOrvE 3 ' PANELS 5.00 DATE OF APPLICATION
ARCHrtECT C (] SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 15.00 !v
APPLICANT'S MOTORS SEE FEE SCH. J
ADDRESS
SERVICE CHANGE 10.00 U Ol/Ok-3
Woo LICENSED CONTRACTORS DECLARATION tom) `r1bp� U/ C
¢v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
ma (commencing with Section 7000)of Division 3 of the Businessand O�Z7 G. ELECT. PLG. MECH.
Professions Co and license is in full force and effect. ❑
0 i u`2 o�"P License lass Lic.NumberT ❑ ❑
2 as J Date ^ Contractor
a m s d > BUILDING PERMIT't^°t,°;'.,,
¢ ¢ W a OWNER-BUILDER DECLARATION _ s:
A O A u MISC.- REFER TO ORD S" :.INFORMATION.,:;,,'.
x ;n N 1 hereby affirm that I am exempt from the Contractor's License VALUATION
w u 0 a Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE
_N 6.00
H W Code:Any city or county which requires construct.¢ ¢ < improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
n a D u requites the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w$ he is licensed pursuant to the provisions of the Contractors License . s1I�p �} 1-
rii Law(Chapter 9(commencing with Section 7000)of Division 3 of the s Y,tyCy '�La S.
a Business and Professions Code)or that he is exempt therefrom and QTY: PLUMBING.PERMIT
¢ .$ [he basis for the alleged exemption.Any violation of Section 7031.5 STORIES altayuT,Y��PE CONSTR.
i ;- by any applicant for a permit subjects[he applicant toacivil penalty ALTER-DRAIN&VENT-WATER IEA.) 4.00 $•U{�B 0'IL_
of not more than five hundred dollars(5500).):
❑ 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,CONO. 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
himselforthroughhisornffemd for
if,ed that however,
the
improve- GAS-EA.SYSTEM-1 INC.4 OUTLETS 4,00
menta are not intended or thin on far sale.If,however,the building
or improvement is sold within one year of completion,the ownerGAS-EASYSTEM-OVER 4(EA.) 100 BUILDING USE
builder will have the burden of Graving that he did not build or im. . . E NO CON PB Om.,
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ L as owner of the property,he exclusively contracting with ❑ ❑ ❑ ❑
licensed cessions ode: 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
to owner of properly who builds improves thereon.and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts -
for such projects with a contrtrpursuantlsl licensed pursuant to
the Co
the Contractor's License Law. SEWER-SANITARY-STORM EA.200(1/5.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,R&P.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4,00 Ace.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 4.00
1 hereby affirm that 1 have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a cer[ificare of Workers'Compensation Insurance,or a certified
X py the. 0,Lab.CkiUle FN'Id
olicy No. � ompany
Q coP ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z ❑ Cert ed copy is filed it the y speni�n division. MISC.• REFER TO ORD. y❑ N❑ v ❑ N❑
ApPlicant �-
2 y C TIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. y❑ N❑ Y ❑ N❑
(This section need not be completed if the permit is for one TOTAL
7 Z hundred dollars IS 100)or less.) -
L.0 O I certify that in the performance of the work for which this per- DTV. - MECHANICAL PERMIT FEEm _'FEE SUMMARY' !,,1 i ,y
LL 1- mi[is issued,1 shall not employ any person in any manner so as to r - _ Y'
U become subject to the Workers Com enation Laws of California.
O tU p BUILDING �1
Dam Applicam ALTER OR ADD TO MECH. 4.001 1
x
} N NOTICE TO APPLICANT: If,after making this Certificate of EA-
F. ? emption,you should become subject to the Workers'L'OMP[as3hon APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10)100C.F.M) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10000C.F.M.) 5.00 SEISMIC FEE Sv
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 ISec. MICROFILM
3097,Crv,C.1. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Na
Lender's Address
me HEATING UNIT(OVER 100,000 B.T.U.17.50 ELECTRIC
I certify that I have read tills applic.tio0 and state that the abOVe VENTILATION FAN (SINGLE) 3.00
information is carrec[. I agree to comply will all city and county PLUMBING
• ordinances and state laws relating to building cons0uction. and BOILER-CR-COMP MECHANICAL
OMP
I3 H.P.or 100,000 B.T.U.) 4.00
IOvm 100,000 BTU)SEE FEE SCH.
hereby authorize representatives of this city to enter upon the BOILE
above-mentioned property for inspection purpuus.
(We) agree to Save, indemnify and keep harmless the City at MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses whichpERM1T ISSUANCE 300 CONST.TAX
.
may in any way accrue against said City in consequence of Elie /I
g nting of th is permit. MECH.CONT, LIC.NO. TOTALG)r/
/
'ignature of Applcanl/Cont Alar Dale o '
OFFICE COPY