6132 AP90CANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
HUILOINc l APPLICATION & PERMIT'
ADDRESS2. - l02 32 u111Ca _
UILDING-ELECTRICAL-PLUMBING-MECHANICAL 6132
OWNER
S ✓D,rCv'-'1 PLAN CHECK VALIDATION
• SNA (,y733-961 OTY. ELECTRIC PERMIT FEE
PHONE
AS
UTLETS-SWITCHES-RECEP 5.00/1.00
N L�1M/91 LIC.NO. 2rOGIG� LIGHTING FIXTURES 5.00/1.00
AONTRASDNTRAcroR's � D� PPLIANCES-RESIDENTIAL 4.00
C
r> 0 r, 1 PHONE��o-igr8` PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER
Lic.No. SIGNS TRANS. 3.00
ARCH.OR ENQSPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP ITEMP.METER OR POLE INS.• 15.00
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE '10.00
C o LICENSED CONI'RACfORS DECLARATION (d'
a u U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
m<w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. I MECH.
H N z Professions Codes and my license is in full force and u;t. ❑ ❑ ❑ ❑
' 0.- LicuE.Class - Lic.Number
O y�2 Date C Contractor tl5typ Ill la 9
2 w ¢
OWNER-BUILDER DECLARATION BUI LgnNq poem IT
0. MISC.- REFER TO ORD `:`INEORMATftON _
w3
w0 1 hereby affirm that I am exempt from the Contractor's License VALUATION f/FT.'
r LL D a Law for the followingneason.(Sec.1031.5,Busin,and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requirexa permit toconstmct,alter,
Qp¢20 Improve,demolish,or repair any stNCWIC.prior to Its Issuance.also ELEC.CONTR. LIC NO. ELEC.
D a, requires the applicant for such permil to file a signed statement that TOTAL PERMIT TO
w m h
e is licensed pursuant to the previsions of the Contractors License
Hzi Law(Chapter 9(commencing WilliSection 7000)ofDivision 3ofthc
¢ Business and Professions Code)cr that he is exempt therefrom and QTYPETY. PLUMBING PERMIT "':FEE
the basis for the alleged exemption.Any violation of Section 703 LS STORIES TE CONSTR.
n3� by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER IEA.14.00 '
or nut Inure than five imndred dollars 18500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 6CC.GROUP RES.UNITS
their,side 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:"rhe Contractor's Licwrse Law does not apply to an owner of
property who builds or improves thereon,and who docs such work O FIXTURES-PER TRAP 4.00 aD,OD 50.FT,FLOOR AREA TOTAL ACREAGE
. himscllare utintended ownemployees,or provided ever,hat the
improve-
penis are nut 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 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Omer
prove for purpose of sale.). - INDUSTRIAL WASTE INTER. 20.00
❑ I,as uwncr,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 Contractors License Law docs not apply to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts 1'or such projects with a contructot(s)licensed pursuant to ^��
life Contractor's License law. ` SEWER-SANITARY-STORM EA.2001t/13.00 9.6M TRACT NO. PARCEL NO.
El lusncxcmptuoder Sec. ,B.&P.C.lirr this WATER HEATER W/VENT 4.0037.00.
reason rt,rT1�
OWIIer Date WATER SYS T EM 4.00 y.vy ACC.DATE ACG FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby al Grin that I huve a certificate of consent to sell-inure. .U!,
s -�C ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Innvanee,or a certified ,
copy rhurcol'IScc.3800,fab,C.l. T � '
Policy No is life ny
Q a Certified py is hereby furnishcd3P -Z.II 1 t�� { f` IOP 11110 FIRE SPR IN
ENERGY,T-14
Z Z O Certifi4 c(spy 's fit 'Iw�tll the ury inspect inn division. MISC.- REFER TO ORD. v N� v Q 4LN�
♦- O Applicant-"�).,v.
CC m CER1'1FICATI:oP F,XEMPTION PROM WORKERS' PERMIT ISSUANCE 6.00 (p,QO FLOOD ZONE A.L.U.C.
LU > COMPHNSA'rION INSURANCE PLG.CONTR. -LIC.NO. PLG. O-C TOTAL YEl N� Y � N�
CL O (This section need or be completed if the permit is for one Q
:D 2 houtreddollars(S 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY' S ,y.•y:,
U H mit is issued.I shalln
not employ any person in any maner so as to
Ow hcconpe subject N the Workeri Compensation Laws of Caliliunia. BUILDING
Oatc Applicant ALTER OR ADD TO MECH. 4.00
} y NOTICE'rO AI'1'LICAN"r: If,after making this Certificate of Ex-
2 enrptiun,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provision of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,OOpGF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00 MICROFILM
the ,cryo inane, of me work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00
3o97,civ.c.). nl'yF-DY19X'vp0,('1co��"T'/1'1c1.
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
(.ends,',Addre��C� �2A
I certify that)[lave feud this application and stare that the above VENTILATION FAN (SINGLE) 3.00 py
information is correct.1 agree to comply With all city and county BOILER-COMP(3 H.P.or 1000000 B.T.U.) 4.00 PLUMBING / 70
ordinances and state laws relating to building construction, and
hereby uuthoriec representatives of this city to enter upon the BOILER-COMP(Over 1°0.000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep Ilannless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
play in any way accrue against said City in consequence of the
granting of this permil. MECH.CONT. LIC.NO. MECH. _
1 - 0 7t_ - TOTAL TOTAL
Signat re ol'Applicant/Cogrector Date
OFFICE COPY