6818 - APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
,BU I LDING PROJECT I DENTt FICATION PERMIT NUMBER
gD,LD,NG 0 APPLICATION & PERMIT
Aooncss
O Q'7- "]_�O ` � vg0 1� UILDING -ELECTRICAL-PLUMBING-MECHANICAL ,t- 6818
1 8
OWNER'.5�� l�L,.aM�GJ1 ;{ l PLAN CHECK VALIDATION
i NnME lLrr PyQ`I.zeV,O /J�1�VV QTY.;" * w "w''.ELECTRIC PERMIT f•�•�• `s FEE,
I �r C ./T VrONEWF• a Y
NANTnncTaR's
NAME '..OUTLETS SWITCHES-RECEP 5.00/1.00
LIC.No. LIGHTING FIXTURES 5.00/1.00
CONTRACTOR aPPLIANCES-RESIDENTIAL 4.00
AOOR ESS '
PHONE PANELS 5.00 DATE OF APPLICATION -
ARCHITECTSIGNS 6.00 - PLAN CHECKFEE ' P.C.NO.
OR J/J
ENGINEERG „r�,/x I.C..NO, SIGNS TRANS. 3.00
ARCH.OR ENG,-7;Z s SPECIALCIRCUIT '5.00 PERMIT VALIDATION
ADDRESS 'Y ('� -
gtq^rO S-q-• CA L. Z, Q TEMP.METER OR POLE INS. 15.00 /
r,
Avvucarvrs
ASS /�7 �+. - /y1/Q'Q.. •S J
DDREMOTORS' SEE FEE SCH.
I
4:fI,2 9S/O9'7 SERVICE CHANGE 10.00
w O o . LICENSED CONT RAC70RS DECLARATION -
<u E, I hereby,affirm that I um licensed under provisions of Chapter 9 ISSUANCE DATE
y< eAi (Commencing-with Section 7000)of Division 3 of the Business and BL ELECT. PLG. MECH.
D z Professions Code,and my license is in full force and effect ❑ ❑ ❑
Q i u,a License Class Lic.Number
F Datc -Contractor
'<y f BUILDING PERMIT
M a w <
OWNER-BUILDER DECLnRA'rloN RG
oAe' -
X S LL y I hereby affirm that I am exempt from the Contractor's License MISC. REFER TO ORD - VALUATION $/FT.
Fuoa Code:Law Any lily or county ing reason.
Sec.7iresa03 perBusmit
toconess dProfessions PERMIT ISSUANCE 6.00 /
Code:Any city or county which requirese permit toconstructalter, O,
Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. - LIC.NO. ELEC.
O a, requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
E
$ he is licensed pursuant to the provisions of the Contractor's License
r z i
Law(Chapter 9(commenting with Section 7000)of Division 3 ofthe - .
i o Business and Professions Code)or that he is exempt therefrom and OTY'. sPLUMBING PERMIT - FEE 7 /�
ICH$ the basis for the alleged exemption.Any violation of5ection7031.5 - ,STORIES TYP CONSTH.
by any applicant for a permit subjects the applicant ton civil penally ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars($500).): -
❑ 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 50.FT.FLOOR AREA TOTAL ACREAGE
- himself Or through his own employees,provided that such improve- GAS-EA.SYSTEM-11NC.4OUTLETS 4.00
meats are not intended or offered for Sale.If,however,the building
or improvement is sold within one year of Completion,the owner. GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
In will have the burden of proving that he did not build or im- RES IND CON PB Orbe,
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
,W 1,as owner of the property,am exclusively contracting with'
licensed contractors to construct the project(See.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.GO ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply -
10 an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 -
contracts fur such projects with a contractors)licensed pursuant to
the C.nouebr's License Law. SEWER-SANITARYSTORM'EA.200ft/8.00 TRACT NG, PARCEL NO.
❑ lamexempf Rude r5 .B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Dale WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby ulfirm that I have a certificate ofemosent to self-insure, ZONING ENG.SITE NO.
or cerliferna of Workers'Compensation Insurance,or a certified
copy thereof(See.3800,Lah.C.L
Policy Nn. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z ZIT Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. Y� N� y 0 NO
O Applicant .
Fy PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
CC - CERTIFICATE OI'EXEMPTION FROM WORKERS'
LU J COMPENSATION INSURANCE . PLG.CONTR. LIC.NO. PLG. y� •N� V� N❑
C O (l his section need not be completed if the permit is for one TOTAL
:3 Z hundmddollars(S100)o Ir--) - F'u x r " Np1. "d'A" S TM`s
U _O I certify that in the performance of the work for which this per )°QTY. MECHANICAI'?PE RMIT+:Y ;aw PEEgia x ' " F.EE SUa M. M��RY
LL F mit Is issued,I shall not employ any person in any manner so as to I y:v
•Ow bemmc lame to the Workers' ompensa ion Lws of CaI la. BUILDING
Da;c.// _Applicant TER OR ADD TO MECH. -4.00
}•N NOTIC P I.ICANT: It aft r making is Certificate of Ex-
F ? eruption,you should become subject to the Workers'Cumpensation 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 10MC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10DMC.F.M.) 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(Sec. MICROFILM
r HEATING UNIT(TO 100,000 B.T.U.) 4.00
J097,Civ.CJ.
Lender's Name z �IY1�lCA HEATING UNIT(OVER 100,000 B.T.U37.50 ELECTRIC
Lender's AddressoJl,A! *- i -
Icertify that lhave read this application and State flat fireabove VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construction. and
hereby authorize representatives of this city-to cnmt upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes. '
rr (We) agree to Save, indemnify and keep harmless the City of MISC.- ' t REFER TO ORD.
Cupertino against liabilities,judgments, Costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may"in any way accrue agat td C'ty i nsequence of the '
gr' 'ago tis permit MECH.CONT'. LIC.NO. MECH:
TorAL TOTAL l
Sr a re of Applicant/ ntractor Dale J
OFFICECOPY