5659 APP; ;�'��n"`:�3�dFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY \
PERMIT NUMBER
r.r
i. L-ATI FICAT_IO
N - APPLICATION & PERMIT
PV Lot SADDREss BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 5659
OWNER.` P . t
PLAN CHECK VALIDATION
INANE
CITY. ELECTRIC PERMIT FEE,
H
CONT ACTOR'S UTLETS-SWITCHES-RECEP 5.00/1.00
NAME
.. LIC.No, LIGHTING FIXTURES 5.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADDRESS , ,
PHONE PANELS 5.00 GATE OF APPLICATION
ARCHITECT SIGNS - 600 PLAN CHECK FEE P.C.NO.
OR
ENGINEERse3,00
LIC,rvo. SIGNS TRANS.
ARCH.OR ENO.�r1 �� //vx f"i OV SPECIAL CIRCUIT '5.00 PERMIT VALIDATION
AODRES$ Ole rYv++'
EMP.METER OR POLE INS. 15.00
APP /307 s. �-fa e y �•�e J MOTORS SEE FEE SCH.
ADDLICAI
g SERVICE CHANGE 10.00
w¢ z (/o
Foo LICENSED CONTRACTORS DECLARATION
a Uw 1 hereby affirm that I am licensed under provisimrsof Chapter 9 ISSUANCE DATE
y a w (commencing with Section 7000)of Division 3 of the Business and a , T. PL❑G. MECH.
F N Professions Code,and my license is in full form and effect {L�.-JT ❑
Z o m License Class Lie Nmnber
o z F w cite Contractor
I,P,�ERMIT
E Q w OWNER-BUILDER DECLARATION EP3F+e ,gTI,ON
w 3 1 m I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO OR
y' p VALUATION S/FT,
en u.o a Law for the following reason.(Sec 7031.5,Business and Professions PERMIT ISSUANCE 6.00 Ity pf��ppJ}Ino
Code:Any city Precocity which requires a permit to construct,after, A OU(J .
:21 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. e
K O a, requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n w m he is licensed pursuant to the provisions of the Contractor's License
Fzi
Law(Chapter 9(commencing with Section 7000)of Division 3 oftheCODdo6. ($ units)
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT- -FEE'-•
IS 1, the basis for the alleged exenhption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant fora permit subjectsthe applicant toa civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00 2 5 N. Hr.
of not more than five hundred dollars($50005:
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 DCC.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 R-1 8
Code:'Eire Contractor's License Law do 5 not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SVSTEM-11NC.40UTLETS 4.00 14 000
tints are not intended or offered for sale.If,however,the building s
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 the did not build or ins- RES IrvD CON PB Omer
prwyv`forpurpow of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑
!1 1,as owner of the property,am exclusively contracting with
h rd contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCE L'NO.
and Professions Code:The Contractor's Licensc Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 269-2-2
contracts for such projects with a amtractor(s)licensed purauont to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the Contractors License Law.
❑ Iamcxcmptm,dcr ' ,B.&P.C.for this WATER HEATER W/VENT 4.00 75755
reason
i Owner/ Uate • � WATER SYSTEM 4.00 qCC.GATE ACC.FILE NO.
WORKERS'COMPENSAT10N DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate cf consent m self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lav C.I. //S--7(�
Poley No. Company
0 ❑ CertilirJ copy is hereby furnished FIRE SPRINK ENERGY T-74
Z Z ❑ Certified copy is filed with Ire city inspection division. MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
I- - Applicant
PERMIT ISSUANCE 6.00 FLOOOZONE A.L.UC.
- CER'I'IFICA'fE OF EXF,MPfION FROM WORKERS'
W > COMPENSATION INSURANCE PLG.CONTR. ❑c.NO. PLG. Y❑ N❑ Y ❑ N❑
l7 '+. TOTAL
CIL 1'fhis section cued not be comp tried if the permit is far enc
Z hundred deltan(S 100)or less.)
U O I certify that in the performance of the work for which this per- GTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner so as to
U been bje-tt the Workcrs'Compensation Laws of California. BUILDING 1 260, 550
0 a Doti�Applicnnt C' �''b �••'+K�� AL ER OR ADD TO MECH.
P;
'
} rn
NO FIJI] P LICANI': 11,aftr making this Crrt ificatn of Ex-
F Z reptlon,you should been subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U inch provisions or this penult shall be dcomed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I10MGflM.) 5.00 SEISMIC FEE 30.17
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the pedimnme ,i�f the work for which this ermil is issued fSec. MICROFILM
3097.Civ.C.). y)A!✓� nGe` HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Nadc, HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
intonation is correct. I agree to comply with all city and countyPLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep armless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, os and expenses which CONST.TAX
may in any way accrue agai n conseque a of the PERMIT ISSUANCE 3CW_.00
p`UPit MECH.CONT. LIC.NO. TOTAL 11290.67
26 TOTAL
igcia[ure of Ap li t/C etractor e
OFFICE COPY
.. is. _ _ _ _