6179 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PENONLY
• '
,BUILDING PROJECT 1 DENTI FICATION '
APPLICATION & PERMIT PERMIT NUMBER
BUILDING
ADDRESS BUILDING-ELECTRICAL-PLUMBING-MECHANICALoo,-ARAIJ DAwe
-6179
OWNER'S PLAN CHECK VALIDATION
4 +n.
Q�TjYg".' +rT =ELEC-TRIC-PERMITr .•m`+ FIE .
PHONE
CONTRACTORS ' UTLETS-SWITCHES-PIECED 5.00/1.00
C
Z.t� / LIc.No 3 (16 LIGHTING FIXTURES 5.00/1.00 Q
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
ADDRESS �
PHON -pYEp(> PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR'
ENGINEER ,
LIC,NO: SIGNS TRANS. 3.00
ADDA'EOSSs ENG SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
APPLICANT s MOTORS ;45 94c SEE FEE SCH.
ADDRESS -
SERVICE CHANGE - 10.00
'02
oO LICENSED CONTRACTORS DECLARATION
<u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE BATE
H G w (commencing with Section 7000)of Division 3 of the Businessand BLDG. ELECT. PLG. MECH.
rm i Professions CodL, dm�y license is in full fof and e ❑ ❑ '
o y m o License Cl Li,Lic.Numbe,ra �a-�¢ PAID
Ki ❑
Date F>L�Cndlraclor p. A
¢ ¢w a OWNIi RBUILUIiR DECLARATION U4 "INFORMATION-'f"- &�c^
wo A" MISC.- R T QR
; r I hereby affirm that I ran.exempt from the Contractor's License VALUATION
r u o a law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires permit to construct,alter,
a¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0, eq[yE
D, requires the applicant for such permit to file a signed statement that Clty IOTAC� PERMIT TO
w he is licensed pursuant to the provisions of the Contractor's license t L���
Zi
Law(Chapter 9(commencingwlth Section 7000)of Division3oRhe a
a' .Business and Professions Code)or that he is exempt thereGom and QTY.' PLUMBING PERMIT - FEE
3 i O
¢ H� the basis for[lie alleged exemption.Any violation ofSection 7071.5 � � r STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(SSOOM:
0 I,as owner fthe 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
properly 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-
menlsare net intended or offered for sale.If,however,the building GAS-EA.SYSTEM'-111NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 .BUILDING USE
builder will have the burden of proving that he did not build or im. RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAUWASTE INTER. 20.00
0 I,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 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply -
to an owner of property who builds or improves thcreun,and who LAWN SPRINKLERS-OVER 5(EA.) 1,00
contracts for such projects with a conlractorl licensed pursuant to
the Contractor's License Law. - I SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this
WATER HEATER W/VENT 4.00
reason
Owner Dale WATER SYSTEM 4.00 WCC.DATE ACC.FILE NO.
WORKERS'COMPF.NSATION DECLARATION WATER TREATING EQUIP. - 4.00
I hereby affirm that I have a certificate ofconscnt to selhinsure' ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,fabC
PoWo. Ae
o"fez^s A
O ' • -
rtified copy is hereby furnished. FIRE SPRINK ENERGY T44
Z Z ❑ Certifi p fill with 1y� it y inspection division.
O Applicant l= �= MISC.- REFER TO ORD. _ y❑ N❑ y❑ N❑
~ T PERMIT ISSUANCE 6.00 FLOOD ZONE- A.L.U.C.
LU > CF.RI'I FICCOEPE EXEMPTION TION FROM WORKERS'
W _ COM not
ora INSURANCE PLG.CONTfl. LIC.NO. PLG. Y❑ N❑ Y ❑ N❑
CL O (This section need not be completed if the permit is for one TOTAL
') Z hu1 ce t•dollaat in
nIthe pe less) ++�."h
U O 1 certify that in'the performance of[he work for which this per- QTY:., a MECHANICAL PERMIT FEE 'FEE SUMMARY,G.'}'
LL F- mit is issued,I shall not employ any person in any manner so as to - ,
become subject to lire Workers'Compensation Laws of California.
Q Date Applicant •BUILDING
a ALTER OR ADD TO MECH. 4.00
} N NOTICE TO APPLICAN"f: If,after making this Certificate of Ex-
F ? emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
f.1 'such provisions or[his permit shall be deemed revoked. AIR HANDLING UNIT(TO 110=11F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT IOVER 1Op00 C.EM.) 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(Sea MICROFILM
3097,Civ-C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lenders Name HEATING UNIT(OVER100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify Ihut I 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 countyPLUMBING
ordinances and state laws relating to building construction, 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 Waar 100,000 BTU)SEE FEE 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 CONST.TAX
may in any wa accrue against aid City in consequence of the -PERMIT ISSUANCE 3.00
grand fll sp r iL b MECH.CONT. LIC.NO. MECH.
lzh/S � TOTAL TOTAL"'
j}� S
Sinalum ofAppliwnt/Contractor Date /
OFFICECOPY