6129 APPLICANT TO FILL-IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER RmL01" APPLICATION & PERMIT
AODREss n
(N BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
6129
Q'^ IO�.r.�2 Nv @.. NV
OwrvER'E 0 PLAN CHECK VALIDATION
NAM, /1roPC.+r`{-y QTY. ELECTRIC PERMIT FEE
�p CKOR5 LOW1l -+'N]V PHONE {3�-�C-/3
N RACTORE OUTLETS-SWITCHES-RECEP 5.00/1,00
N E .n1 Urrn y" LIc.No,Z6G160 LIGHTI NG F IXTURES 5.00/1.00 /
CONTRACTORS lvl �I PPLIANCES-RESIDENTIAL 4.00
ADIDDR Ess
/ 7 ,� PHONE 3�0 -In PANELS 5.00 DATE OF APPLICATION
»� � .
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.rvo. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
00 LICENSED CON'fRACI'ORS DECLARATION
n: u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y Q m (coin....acing will,Section 7000)of Division 3 of the Businuss and BLDG. ELECT. PLG. MECH.
F m z P fessions Code and Hall is in full force an l effect. ❑ ❑ ❑ ❑
2 O m- Laenw Clue_d.�t/ S Lic.Number ' ^ p
Q Y IJatc 16-2�T Ca,tmctor
¢ w¢ OWNER-BUILDER DIiCLARAIION, BUILDING PERMIT
D REFER TO ORD INFORMATION"
w3 LL r I hereby infirm that I am exempt from tlm Contractor's License MISC.-
uoa Law for the following reason. 703 L5.Business and Professions PERMIT ISSUANCE VALUATION S/FT. P
_ 6.00
Code:Any city or county which requires permit to construct,alter,
6 Q improve,demolish.or repair any structure',prior to its issuance,also ELEC.CONTR. ELEC.
O , requires the applicant I'ur such permit In file a signed statement that TOTAL PERMIT TO
n w m he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
¢ Ilusiness and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption.Any violation of5ection 7031.5 STORIES TYPE CONSTR.'
cc by my applicant for a permit subject,the appliganl to a civil penally ALTER-DRAIN -WATER (EA.) 4.00
Of not mum Ihun five hundred dollms($500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 oce.GROUP RES.UNITS
their sole c)mpensatiun,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 Contractors License Lute does not apply t0 an Owner of Tn
propertyµ11O builds(it III1prOvcs IIcrCOn,and who does[LIGE work 0 FIXTURES-PER TRAP 4.00 17,-Q.vV SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided dust such improve-
mentsale nmintended oroffered For vIt,If,however.the building GAS-EA.SYSTEM-11 INC.4 OUTLETS 4.00
r 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
❑ 1,as owner of the property,ant 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 does not apply ,
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts fur such projects with a contractor(s)licensed pursuant to
the Contractor;License Law. �2Qd SEWER-SANITARY-STORM EA.200ft/8.00 $.(TD TRACTNo. PARCEL NO.
❑ lamexanptondcr Sec. ,B.&P.C.Ii)rthis WATER HEATER W/VENT 4.00 5Z.6b
reason
Owner Date WATER SYSTEM 4.00 'Y,M ACC.DATE ACG FILE NO.
WORK BRS'COMI'ENSA'I ION DECLARATION WATER TREATING EQUIP. 4.00 '
I hereby affirm that l have a certificate of Consent to scl Hinsure, ZONING ENG.SITE NO.
or a certificate of Worker;Compensation Insurance,or a certified
copy thereof(See 3800,Lab.0-L�'"_ '
Policy No. Company�i s�sa��
0 /Td Certified copy is hereby fumisheJ.3Y Z)) Z� FIRESPRINK ENERGY T-24
❑ Certifte{f.Copy 's f+led� d11 the city inspection division. MISC.- REFER TO ORD.
H p Applicant_ w�.l -1�.a'� y❑ IN Y❑ "❑
IY L4 CER'1'IPICAT1:OI'Ii XIiMI"If ON PROM WORKERS' PERMIT ISSUANCE 6.00 ro.0 FLOOD ZONE I A.L.U.C.
LLI > COMITNSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
D' IThiz section need not he completed if the permit is for one TOTAL Q Y IN El Y N�
2 hundred dollars($100)or it '
U O 1 certify IIIat in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE;SUMMARy",,:','s}}gs,-',',
U_ H mit is issued.I shall not employ any person it :my marinenm as to
V bom
live Subject to the WOfkeD'Coen
mpsation Laws of California.
0 a Date Applicant ALTER OR ADD TO MECH. 4,00 BUILDING is
} W NOTICE;1'0 APPLICANT: IL after making this Certificate of li x- r
z emptlon,yoo should become subject to the workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, YOU must forthwith comply with FEE
U stmh provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MO QRML) 3.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00GEM.) 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(Sec. MICROFILM
3097,Civ.C.). IS S- /1kov�n HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name kns (�y`"'Tf 61 HEATING UNIT(OVER 100,000 B.T.U.P.50 ELECTRIC
Lenders Neon, f 1 >6 _Pi+`jP"r 1 ^? ft,
I Certify that I have read thisapplicalion and state that the above VENTILATION FAN (SINGLE) 3.00
infonnmiot, i Corect. I agree Io comply with all city and County PLUMBING /17Q `i
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00
hereby authuriLe representatives Of this city to enter upon the BOILER-COMP(Over 100,000BTU)SEE FEESCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree to Save, indemnify and keep hinnless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments,costs and expenses which _PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against mid City in consequence of the
gr lipg of this pemrl. - �Ltli MECH.CONT. UC.NO. MECH. ,
` TOTAL TOTAL
Si atu a of Applicant/Contractor .Date
OFFICE COPY