6130 „ ^ APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -,USE BALL POINT PEN ONLY
)BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
' AooREss 1
Oz o r� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL _ 6 1 3O
OWNER'S PLAN CHECK VALIDATION
NAME q / - l°b'>f1C0'y�''�Gf -rZJ/p QTY. ELECTRIC PERMIT - ; '.FEE
W a1 q n PH N / J� (I IC 1 .a .. i..
CONTRACTOR S
NAE 26CA(GO UTLETS-SWITCHES-RECEP 5.00/1.00
O' PS41 LIC.NO. LIGHTING FIXTURES 5.00/1.00 '
CONTRACTOR'S �,1j�Ay1I
ADDRESS
' V_s, PPLIANCES-RESIDENTIAL• 4.00 _
PHONE PANELS 5.00 DATE OF APPLICATION
ARRCHITECr ' SIGNS - 6•00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.NO. -SIGNS TRANS. 3.00
ADDREss ENC, _ SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zip rrEMP.METER OR POLE INS. 15.00
APPLICANT'S - MOTORS - SEE FEE SCH. p
ADDRESS \^}J/�J�
- . SERVICE CHANGE 10.00"-
0.00 QJ(f
2
0
D / T
Foo LICENSED CONTRACTORS DECLARATION </
u w I hereby affirm that I am licensed under provisions of Chaplet 9 ,ISSUANCE GATE
y Q m (commencing with Section 7000)or Division 3 of the Business and BLDG. ELECT. PLG." MECH.
Hoz Professions Cod and y license is in full force and effect ❑ ❑ ❑ ❑
0 i I°it o
License Class tic Number 0
Date I[I JContractar '
It
ams, J "IBDICDINO PERMIT
¢o i OWNER-BUILDER DECLARATION ' '��'"n. '. INFORMATION
X 3 u 1T' '1 hereby affirm that 1 am exempt from the Contractor's License MISC.- - REFER TO ORD VALUATION S/FT.
a.0 a Law for the following Lesson.(Sec.7031.5,Businessand Professions
H - g PERMIT ISSUANCE 8.00
Code:Any city ur county which Mquiresa permit to construct,alter,
a,aa
a p improve,demolish,or repair any situclure,prior to its issuance,also ELEC.CONTR. LIC.rv0. ELEC.
D u requires the applicant for such permit to file a signed statement that TOTAL -
A w m he u ntra
licensed Pursuant to the provisions of the Computer's PERMIT TO
License p
H z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
tai
f 4 o Business and Professions Code)or that he is exempt therefrom and QTY 'ti 6 r iP'LUMBING PERMIT
SE H Q the basis for the alleged exemption.Any violation ur Section 7031 5 I sh % � 4'""!x'' STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not mom than five hundred dollars(S500).):
❑ 1,as owner of the properly,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 3jp FIXTURES-PER TRAP 4.00 .6D SEE FT.FLOOR AREA TOTAL ACREAGE
• hints are not intended
ownemployees,fors, l,Iidedthalsucb improve- GAS-EA.SYSTEM-1 nlenls are molintended orthin on forsale.If,however,the building
or improvement is sold within one year of completion,the owner-
builder will have IhC burden of proving Ihm he did not build or on, GAS-EA.SYSTEM-OVER 4 1EA.1 - 1.00 BUILDING USE
Prove for Purpose ofsale.). - RES IND CON PR . Other
❑ 1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 20.00 ❑ ❑. ❑ ❑ ❑
licensed contractor to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Cade:The Commctor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a conlruclons)licensed pursuant to
Lite Contractor's License Law. *
SEWER-SANITARY-STORM EA.200ft/8.00 5%0 TRACT NO, PARCEL NO,
❑ lam exempt under Sec. ,N.&P.C.I,),this
WATER HEATER W/VENT 4.00 "67-M '
maNon'
Owner - Date WATER SYSTEM 4.00 �J
�/.� ACC.DATE eACC.FILE NO.
.WORKIiRS'COMPIiNSATION DECLARATION WATER TREATING 1 1T'• 4.00 v
I hereby affirm that 1 have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Cnmpensation Insurance,or a certified
copy thereof(Sec..3800,1.ab.0 I
Policy No. Company_F- 1A2 -
O /�3 Certified copy is hereby furnished.:5 7.11 �1 FIRE SPRINK ENERGY T-24
Z 2 ❑ Certifle copy is File with.tine city inspection division. MISC.- REFER TO ORD.
Q APPlicanl_h-ge Y❑ N❑ Y❑ N❑
KN CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 .6 FLOOD ZONE A.L.U,C.
Lu •- COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. / O I�'O Y❑ N❑ V❑ N❑
•d O (This section need not be completed if the permit is rot one TOTAL
2 hundred dollars(S 100)or less.) y s
U 1 certify that in the performance of the work for which this per Q.Fy/9 k''9"� y., . FEE SUMMARY>''l
U I mit is issued,l shall not employ any person in any manner so as to MECHANICAL PERMIT,. FEE, kt;•
O w become subject to the Workers'Compensation Laws of California. a ° '
Q. Uam ApplicantALTER OR ADD TO MECH. 4.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ek- _
cmption,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 ITO 10=&F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.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 IS". - - MICROFILM
3097,Civ.CJ. /� HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name.r�Y m01'
5tmIs
Lenders Addm1x 1111 �_Cf xrl{',' HEATING UNIT(OVER 100,000 B.T.U.17.50 ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
•-�� information is correct. I agree to comply with all city and county - PLUMBING lTQ
ordinances and state laws relating to building construction, and BOILER-OOMP(3H.P.Or 100,0008.T.U.).4.00
hereby authorize representatives of this city to enter upon theg01 LER-COMP Over 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, costsand expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against mid City in consequence of the
• grunting of this permit. MECH.CONT. . LIC.NO. MECH.
na,VM *� 10-Z LI TOTAL TOTAL.
+
Signatalm of Applicant/Co tractor Date
OFFICE COPY '