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6951Dai woo 0) O ZZ I"Vi CC W _ ao Z Uo_ LL Ow } taia ),- Z A APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT BUILDING - ELECTRICAL- PLUMBING - MECHANICAL PERMIT NUMBER 6951 AUi,WND / aUDREsS l7C%i OWNER'5 NAME /�f�/)l -: C.%: l7r�y1•�.f� PHONE 'I^ t ° R ?� r�rz '`'rpr��µµ'3qq�r�Y:�PiTttS ''l1" 'See. 'F 'h 1 «/'. PLAN CHECK VALIDATION DATE OF APPLICATION e0 ACTOR'S �'wi 11C.ND hL UTLETS-SWITCHES-RECEP 5.00/1.00 el -7 T . LIGHTING FIXTURES 5.00/1.00 .7 CONTRACTOR-6 p-'1%ye /.),//. ✓'�(/i PHONE N0 ! PPLIANCES- RESIDENTIAL 4.00 PANELS 5.00 ARCHITECT ENGINEER LIC NO. SIGNS 6.00 PLAN CHECK FEE P.C. NO. ISIGNS TRANS. 3.00 ADDDRESS ENO SPECIAL CIRCUIT 5.00 PERMIT VALIDATION EMP. METER OR POLE INS. 15.00 ZIP_ - S APPLICANTL I ,�a T ¢_ J vv(/✓[.i rll L/J7/L� /l%iti.Covl >y 6f litµ` �•/� MOTORS SEE FEE SCH. SERVICE CHANGE 10.00 LICENSED CONTRACTORS DECLARATION ��� �;_ I hereby affirm that 1 am licensed under provisions of Chapter q ISSUANCE DATE tcommencing with Section 7000) of Division 3 of the Business and Professions Code, d license is in full force ar/dH a [u License ClpSs/`' Lic. Number 7D t. DateJ.Z _/jrContraclor- _ BLDG. ELECT. I PLG. MECH. ❑ ❑ ❑ -- "' *":(,`M°' BUIL'DING'PERMIT ��'•' -SINFOfiMAT10N�' Ez OWNER -BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License Professions Law fornycitthe followingrountywhih requireta peusit to permit toconsuance, also Code: Any city or county which structure, Or repair any permit Imprnee applicant to fi Atlee In Its issuance, that requires theapplicantfor such Permitto filenxContstmr's License licensed pursuant en the provisions of the Contractor's License he is (Chapter Lew(Chapmr 9(commencing with Section 7000) ofDivision Sof the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of$edion ]031.$ MISC. - ',REFER TO ORD VALUATION SIFT. CE PERMIT ISSUANCE 6.00 �;, ELEC CONTR. I LIC NO. ?/ ;'` p/((.hleL / r, EIEC. / J� TOTAL fp'y,G(.' PERMIT TD ZG L7 e t�"'' DTV` .,'� jH'tfY' 'l.0.,°., ;y>+gX;; --'� Y' <PCUMBING,PERMIT ,(1q�ts' FEE' A.;uL-k!i'f::1�=.t%vfw'E �:a-JaLb.'t _ Y ,FEE' STORIES TYPE CONSTR. by any applicant for a permit subjects the applicant too civil penalty of not more than five hundred dollars(5$001.1: gLTER-DRAIN ENT•WATER(EA.) 4,00 ❑ I. as owner of the property, or my employees wish wages as their sole compensation, will do she work, and the stmcture is not intended or offered for sale (Sec. 7044, Business and Professions BACK FLOW PROTECT. DEVICE 2,00 DRAINS -FLOOR, ROOF, AREA, COND. 4.00 oCC. GROUP RES. UNITS Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work FIXTURES - PER TRAP 4.00 SQ FT. FLOOR AREA TOTAL ACREAGE himself or through his own employees, provided that such improve- mentsarehot intended oroffered for sale. IL however, the building GAS -EA. SYSTEM -1INC. 4 OUTLETS 4.00 or improvement is sold within one year of completion, the owner- builder will have the burden of proving that he did not build or im. prove for purpose of sale. 1. ❑ h as owner of the property, am exclusively contracting with licensed contractors ho construct the project (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon. and who GAS - EA. SYSTEM - OVER 4 (EA.) 1.00 BUILDING USE RES IND CON PB Other ❑ ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 20.00 LAWN SPRINKLERS - 1 INC 5 V.B. 5.00 LAWN SPRINKLERS - OVER 5 (EA.) 1.00 ASSESSORSPARCEL NO. contracts for such projects with a contractorls) licensed pursuant to the Contractor's License Law. SEWER -SANITARY -STORM EA. 200ft/8.00 TRACT NO. PARCEL NO. ❑ lam exempt under Sec.-, B.&P.C. for this reason WATER HEATER W/VENT 4.00 Owner Date WATER SYSTEM 4.00 ACC. DATE ACC. FILE NO. WORK ERS'COMPF-NSATION DECLARATION WATER TREATING EQUIP. 4.00 1 hereby affirm that I have a cenificaW ufc.,,sxut to self -insure, or a certificate of Workers' Compensation Insurance, or a certified ZONING ENG. SITE NO. copy themoof((SSec.c-L380f). L b.C.l. ' Policy No. t�IAISIPanY s.lC'1 �^IYL'f1 ❑ Certif copy is erebyfurnished. ❑ Certified Fogy` filed lh�NQU inspection division. Applicant I C �- FIRESPRINK y N ❑ ❑ ENERGY T-24 y N ❑ ❑ MISC.- REFER TO ORD. 1PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C. PLG.CONTR. LIC. NO. PLG. TOTAL COMPENSATION INSURANCE (This section need not be completed if the permit is for one Y ❑ N ❑ Y ❑ N [3 -.r„ rFk r,:Y.Y' CITY WMECHANICAL PERMIT -h )A -(c i 3FEEY d• C -yh1 W ",'.fix- ,�yFEE SUMMARY - rl hundred dollars (S 100) or less.) I certify that in the performance of the work for which thss per mit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of Celifomia. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Ex- emption, you should become subject to the Workers' Compensation provisions of the Labor Code, you muss forthwith comply with Such provisions or this permit tha11 be deemed revoked. BUILDING ALTER OR ADD TO MECH. 4.00 APPLIANCE 4.00 PLAN CHECK FEE AIR HANDLING UNIT (TO 10)70DC.F.M.) 3.00 AIR HANDLING UNIT (OVER 10p00GF.M.) 5.00 SEISMIC FEE CONSTRUCTION LENDING AGENCY EXHAUST HOOD (WITH DUCT) 2.00 MICROFILM I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued $Sec. 3097, Co.C.). Lender's Name HEATING UNIT (TO 100,000 B.T.U.) 4.00 HEATING UNIT (OVER 100,000 B.T.U.)7.50 ELECTRIC Lender's Address 1 certify (hat I have read this application and stale that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and VENTILATION FAN (SINGLE) 3.00 PLUMBING BOILER- COMP (3 H.P. or 100,000 B.T.U.) 4.00 BOILER -COMP IOvm 100,000 STU) SEE FEE SCH.1 MECHANICAL hereby authorize representatives of this city to enter upon the above-mentioned propeuy for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses whichCONST. may in any way accrue against Said City in consequence of the gran(ingofthis perms(!. �.�� % (•'L'(�f`, /'Yl JI �r�7' MISC. - REFER TO ORD. TAX PERMIT ISSUANCE 3.00 MECH. CONT. LIC. NO. MECH. TOTAL 'o. EIJ,!a/f ^,•d'7%i( .'OW.�• �` �t�f fir ;T.OTAL Signature of Pllceht(Contraetor Lfitte OFFICE COPY'