6930 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
...R.a g 7 APPLICATION U PERMIT 6930
O .• /d.2X? A.vc BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OwNE.54c �E27Y.t..�JDA,ti `yF� ` PLAN CHECK VALIDATION
NAME n`/a/y QTY. ELECTRIC PERMIT FEE
PHONE
CONTRACTORS OUTLETS-SWITCHES-RECEP 5.00/1.00
NAME
.•� S uO'No$$ $S'O LIGHTING FIXTURES 5.00/1.00
AEmHESOroR's PPLIANCES-RESIDENTIAL 4.00
PHOrvE 9 PANELS 5.00 DATE OF APPLICATION
ARCHITECTSIGN$ 6,D0 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
' uc.NO ' SIGNS TRANS. 3.00
ARCH.OR ENG, SPECIAL CIRCUIT. 5,00 PERMIT VALIDATION
ADDRESS
ZIP rrEMP.METER OR POLE INS. 15.00r-
APPLICANT'a MOTORS SEE FEE SCH.
Amm ESs
• SERVICE CHANGE 10.00 /
Foo LICENSED CONTRACTORS DECLARATION
G v u I herchy affirm Ihut I am licensed under provisions of Chapter 9 ISSUANCE DATE
w G m (wmmencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F D z Professions One and my�lice�nse is in full force and effect.
IRI
z O m- License Clas� [• Lia Numb ❑ ❑ ❑
o F w Dat.L�r47�F Contractor
ae w ¢ OWNER-BUILDER DECLARATION BUILDING PERMITS
o A " MISC.- REFER TO ORD -INFORNI%1TIUN;,_._
wg LL y I hereby off nn Ihrt I am exempt from the Contractor's License VALUATION S/FT.
FLLOj Law I..the Billowing reason.(Svc.703 1.5,Businessand Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a Permit to construct.atter,
Qin improve,demolid,orrepair anyslrucum,prior to its Issuance,also ELEQ CONTR. LIC.NO. ELEC.
i] ¢ requires the applicant for such permit to file a signed s1ulCmern that TOTAL PERM! TO
a w m" be islicensed pursuaRl to the provisions of the Contractor's License
Law(Chapter')(mmmencing with Section-7000)of Division 3 of the Mf'
a Blaine,,and Professions Code)or that he is exempt thercfnno unit OTV. PLUMBING PERMIT FEE
¢ r p the basis for the alleged exemption.Any violation or Section 7031.5 STORIES TYPE CONSTR.
n ; w by any applicant for a permit subjects the applicant too civil penalty gLTER-DRAIN&VENT-WATER (EA.) 4.00
of not... e than five hundred dollars($500).):
❑ I,as owner )I 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 4.08 a0.FL FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided,that such improve'
mre
mems are not intended or offend for sale.If,however,the building GAS-EA.SYSTEM-l1NC.40UTLETS 4.00
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 Pe Oruro
prove for purpose f,.C.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors t0 construct the project(Sec 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:'I'he Contractor's License Law does no(apply
to an owner of property who builds or improves thereon,and who LAWNSPRINKLERS-OVER 5(EA.) 1.00
contracts for such Projects with a contractods)licensed pursuant to SEWER-SANITARY
Y-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the('oniracon's License Law.
❑ ani cxemptundcr Scc. .B.&PC.for Diii WATER HEATER W/VENT 4.00
reason
Owner Date WATER.SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPENSA'rION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affrin that I have a ecrtilicute ofconsent to sel Ginsure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a cer ilml
Copy thurq>(fle0� 'ib
Polic i puny
(] ❑ Cortiic t'o,I,I,Crr1y Iumi,Ii,d. FIRE SPRINK ENERGY T 24
Z_ Z ❑ Ccrtil'ic ,_ y !a p1'l�e Tw�iti lks sitz inspection division. MISC.- REFER TO ORD. v N v N
O Applicant Ibe x'Lalli��e!// ❑ ❑ ❑ ❑
Iry \\\ � PERMIT ISSUANCE 6.00 000 ZONE A. .u.c.
cc > CERIFICATEOF EXEMPTION FROM WORKERS'
LU _ COMPENSATION INSURANCE PLG.CONTR. LIC.No. PLG. Y❑ N❑ Y E] N❑
CL O ('Phis section need not be Completed if the permit is for one TOTAL
Z hundred dollar,($100)or less.)
U O I certify that in the performance of the work for which(his per- OTV MECHANICAL PERMIT FEE FEE SUMMARYy�(., ,
LL F mit is issued,I shall not employ any person in any manner m as to _
19
O U become subject to the Worked Compensation Laws of California. BUILDING
UateApplican( ALTER OR ADD 4.00
>_ tui) NOTICE TO APPLICAN'C If,after making this Certificate of Fx-
Z emptlon,you should become subject to the Workers'Compensation APPLIANCE4.00 PLAN CHECK
provisions of the Libor Code, you must forthwith comply with / FEE
ro
U such pvisions or this permit shall be deemed revoked. AIR HANDLIN U IT(T040 .M.) 3.00
CONSTRUCION LENDING AGENCY AIR HANDLING UNIT(OVER 10)OpDC.F.M.15.00 SEISMIC FEE
I hereby alfino (hut there is a construction lending agency for EXHAUST H00Di(WITH DUCT) 2.00 (�
the perinonance o1'the work for which this permit is issued(Sec. MICROFILM
3097 CivC) HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Numc H EATING UNIT(OVER 100,000 B.T.U.17.50 ELECTRIC
Lcuders Address
I cer(IIy that I have read this application and state that the above O VENTILATION FAN (SINGLE) 3.00 L
into mniation is correct.1 agree to comply with all city and county g01LER-OOfx�(3 H.P.or 100,0006.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over IWLOOOBTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.' '---�
(Wo) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino ugains[ liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00 ,3
gmnlin thi'permit. MECH.CONT. UC.NO. MECH. - .
TOTAL
'7 C TOTAL
Signmum of Applican baste' Umc
OFFICE COPY