6181 'APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
/• BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BDILDINt'. APPLICATION & PERMIT ^
ADOREss b
ray O. BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAMF QTY. ELECTRIC PERMIT FEE
HONE
DOrvTRAcrORs
NAUTLETS-SWITCHES-RECEP 5.00/1.00
ME _
/C__ LIC.No. i ObLIGHTING FIXTURES 5.00/1.00 O
CONTRACTORaPPLIANCES-RESIDENTIAL 4.00
ADDRsss
7RJ�/1SPHOry Jbo0 PANELS 5.00 f� DATE OF APPLICATION
ARmnTECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
NGINEER
uc.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. SPEDIAL CIRCUIT 5.00 PERMIT VALIDATION
ADnRE55
ZIP TEMP.METER OR POLE INS. 15.00
AMPESS
ADORES$ MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
oz //ey
0 /D `/
o o LICENSED CONTRACTOR$DECLARATION � !Q/ / ((� r,
a v u I hereby affirm that I ma licensed under provisions of Chapter`) ISSUANCE DATE
nQ H (fonunencing wLLh$edion ]0001 of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H N z Professions Code hand my license is in full for,a�nd effect. ❑ ❑
z O H - License Cla �J�Lia Number_y� ff ❑
Is
w Datn yfQf/ Contractor BUILDING PERMIT
Wu - OWNER.BUILDER DECLARATION , INFORMATION
a 0 a I hereby flirnl that I am exempt from the Contractor's License MISC.- REFER TO OR
X 3 r Ya p VALUATION $/FT.
F u. 0 J Law for the following reason.(See.7031.5,Businessand Professions PERMIT ISSUANCE 6.00
Code'.Any city or county which requires a permit to construct.alter, [�A
2 a, Q 2O improve,demolish,or repair any structure,prior to its issuance,also 'ELEC.CONTE. LIC.NO. Q't
ELEft� r
-O LL requires the applicant for such permit to lilt a signed statement that TOLL PERMIT TO
A w m he is licensed pursuant to the provisions of the Contractor's License
r z i LawlChapter 9(commencing with Seclion 7000)of Division 3 of theOCC�O-
Itusincss and professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT !�t ojFgBp 1R
0 the basis for the alleged exemption.Any violation of Section 7031.5 C7 1 STORIES TYPE CONSTR.
d � by any applicant for a permit subjects the applicant Ica civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(5500).1:
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole contpnuation,will do the work,and the structure is not
intended Or otfered for sale (See 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 dues such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale.If,howmer.the building GAS-EA.SYSTEM-I1NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4(EA.) 100 BUILDING USE
builder will have the burden of proving that he did not build or int- . . .
RES IND CON PB Omer
prove for purpose f.de.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ 1-1 1:1 El
I,as owner Of the property,am exclusively contracting with
licensed contractors to construct the project(Sec.7144,Business LAWN SPRINKLERS-I INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Pm@ssions Code:The Contractor's License Law does not apply
to anone,of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
con trn:Ids for such projects with a contractor(s)licensed pursuant to
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ Iamexempt,ruder See ,B.&P.C.forthis WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARA'NON WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate ofconsent to self insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sve.3800,Lab.C.)/�� S Z•xQ
Polic N.. Coup,,ny/ C e
Q Ccrtilied copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z_ Z ❑ Certified c y led�will,� 11 .1 inspection division. MISC.- REFER TO ORD.
O Applicant Y❑ N❑ Y ❑ No
F-' w PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
Lu � CIiRI'I FICCOI OF EXEM N INSUROAI WORKERS'
W COM notbeT oat INSURANCE NCC PLG.CONTE. LIC.NO. PLG. Y❑ N❑ Y❑ N❑ -
' d O (This sectidn need not be complete) if the permit is for one TOTAL
Z hundred dollars 1$100)or less.)
U O 1 certify that in the performance of the work for which this per- FEE SUMMARY
LL F- mit is issued, I shall not employ any person many manner so as to
U becomesubjecl to the Workers''Compensation laws Of C4lifomia.
UJ
Date Appll`ant ALTER OR ADD TO MECH. 4.00 BUILDING
} rn NO1'ICI7 '10 APPLICANT: If,after making this Certificate c, F.x-
F Z 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
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
I' CONS FROM ION LENDING AGENCY AIR HANDLING UNIT(OVER IOADOC.F.MX5.00 SEISMIC FEE.
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance ul'the work for which this permit is issued(Sec. MICROFILM
3097,CIyCJ. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Num° HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC SSV
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. 1 agree to comply with all City and countyPLUMBING
oNrm
inces and state laws palating to building construction, end BOILER-COMP(3 H.P.or 100,000 B.T.U.)-4,00
hereby authurire representatives of this city to enter upon the BOILER-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, costs and expenses which CONST.TAX
may m a way he"ue 'inst said City in consequence of the PERMIT ISSUANCE 3.00
S*
ing lh s P'nut. MECH.CONT. LIC.N0. MECH.
�� �5 /11, � TOTAL TOTAL
Sigprommor pphcant ontraaor U m
OFFICECOPY