6928 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDIor. APPLICATION & PERMIT 6928
ADDRESS �� /a 232 6 3
BUILDING — ELECTRICAL-PLUMBING—MECHANICAL
VAV
upMERS CUQEi�T/f�O YYN CPMi�i PLAN CHECK VALIDATION
QTY. ELECTRIC PERMIT FEE
OZQO/t,[ PHONE
NONrnacloRs UTLETS-SWITCHES-RECEP 5.00/1.00
NAME
/ LIc rvDLIGHTING FIXTURES 5.00/1.00
ADDRESS
•ADSe's APPLIANCES-RESIDENTIAL 4.00
ADDRESS
��� V PHDNE PANELS 5-00 DATE OF APPLICATION
ARC HIRECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
ADDRESS ENc. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00
ASPUCAWT"S MOTORS SEE FEE SCH. J
ADDRESS
SERVICE CHANGE 10.00 /N�Ole fi
w O o LICENSED CONTRACTORS DECLARATION
a W I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w<c (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H w z Professions Gsile,and_ my license is in full force and cffC — ❑ ❑ ❑ ❑
z o w— License Class—
Lic.Numbe-
0 t- ° 1)ate /� CommO0, ..
w _
a E - BUILDI,/;1G,PhERMIIT F
¢ a¢ OWNER-BUILDER DECLARATION Y'L
¢ os MISC.— REFER TO ORD INFORMAIONa,
X 3 r I hereby of llo that I so exempt from the Contractor's License
tcO j Law far the following reason.(Sec.703 L5,Business and Professions VALUATION 5/FT.
t — Code:Any city or county which requiresa permit tuconstruc(,alter, PERMIT ISSUANCE 6.00
¢
¢ 0 improve,den...Ikh,or repair any structure,prior it)its issuance,also ELEC.CONTR. LIC.NO. ELEC.
ur — ¢ requires lire applicanl for such permit to file a signed statement that - TOTAL PERMIT TO
III ' w m u- he Is licensed pursuant to the provisions of the Contractor S License - /
Law 9(commencing with Section 7000)of
Hzi Division 3 ofthe ML1-�7"'
FEE
Business and Prrfessiuns Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT
¢ 0 the basis for the alleged exemption.Any violation oftiectiun 7031.5 STORIES TYPE CONSTR.
u ;� by any applicant for a permit subjects the applicant o a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars($5001):
❑ I,as owner of the property,or my cnmloyces with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITStheir sole compensation,will Jo the work,and the structure is not
intended or offered for sale(Sec. 7144, 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 docs such work FIXTURES-PER TRAP 4.00 SQ FT,FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
meets are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvemmot 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 the did not build or im- RES IND CON PB Other
Prove for purpose of IINDUSTRIAL WASTE INTER. 20.00 ❑ o
❑ I,as owner or the property,Ion 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 docs 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 conrracturls)licensed pursuant to
ere Contractors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lura esengst under See ,B.&PEC.fur this WATER HEATER W/VENT 4.00
reason
Owner Uutc WATER SYSTEM 4.00 ACC.-DATE ACC.FILE NO.
WORKERS'COMPFNSA'IION DECLARATION WATER TREATING EQUIP. 4.00
I hereby atlirm that 1 have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Conspcnsation Insurance,or a certified
copy theryyISec 39�00 b.CJ.
any-
0 Policy NbY[2
❑ Ccrlllicd ' py ss hachy lumished.- FIRESPRINK ENERGY T-24
Z Z ❑ Certi(ie ropy is I with he City inspection division. MISC.- REFER TO ORD. YE] N� v � N�
F O Applicant_k�,,,
N CERT'I19CA1'1:01'EXEMI'1'ION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE AT.UC.
Lu > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. v NF] Y N�
CL D (This section need not be completed if the permit is for one TOTAL
D 2 It undmd dollars IS leo)er less,)U r,,.
O I certify that in the performance of the work far wit DTV
ich this per- _ FEE SURY':MMA
F mit is issued,1 shall not employ any person in any manner so as to . MECHANICF,�L•PERMIT FEE ."V�'sy,:
Ow beconmsubjemt to the Worker'Compensation Laws of California. 1Vy BUILDING
Date Applicant ALTER OR ADD TO MECH. t 4.00
} ED NOTICE' 1'0 APPLICANT': If,after making this Certificate M Ex-
? currier,you should become subject le the Workerx'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 HANDLIN 'UNIT(TO 10,000 1 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING Ul`J s 1 C.RM-) 5.00 SEISMIC FEE
I hereby affirm that them is a construction lending agency for EXHAUST HOOIYIWITH DUCT) 2.00
the permrmmnee of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ.C.T
Lender's None HEATING UNIT(OVER100,000 B.T.U.)7.50 ELECTRIC
Lenders Address
I certify that I have read this application and stale that the above VGL
ENTILATION FAN (SINE) 3.00 U
• informationis correct.I agree to comply with all city and county PLUMBING
anti nd state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,0008.T.U.) 4.00
hereby :nnhoriec representatives of this city to enter upon the BOILER-COM ,O OO BTU)SEE FEE SCH. MECHANICAL C.--
above-mentioned property for inspection purposes.
(We) agree to Save, indemnify and keep harmless rhe City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which '` CONST.TAX
may in any way accrue against said City inconsequence of the PERMIT ISSU Nl3CE 3.00 3
grant of this permit. MECH.CONT. LIC.NO. MECH.
LIC._
TOTAL 7/ d TOTAL
Signamreof Applican D
ronlacror a ate ,t 01
OFFICE COPY