5206 C a i� • ralo J
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -.USE BALL POINT PEN ONLY '
• BUILDING PROJECT I DENTIFICAT16N 5 PERMIT NUMBER
^/ SO,LDINGAPPLICATION & PERMIT
ADDRESS
•��0� u� BUILDING-ELECTRICAL-PLUMBING MECHANICAL 5206
OWrvER'S /C/ i J 111.Y.fppp :, Ta I PLAN CHECK VALIDATION
''L E �+ Lt'GYn{n
ELECTRIC PERMIrT4
�j
CONTRACTORS UTLETS-SWITCHES-RECEP 5.00/1.00
�OJs� sec.rvgz2,/^ LIGHTING FIXTURES - 5.00/1.00
CONTRADDRESS ons S(Og PPLIANCES-RESIDENTIAL ' 4.00
AS
t PNON 1 PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
vGINEE
Q.f?// sec.No.0 y3�6 SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
® - ZIc EMP.METER OR POLE INS. 15.00 J
APPLICANTS MOTORS - SEE FEE SCH.
ADDRESS
rU SERVICE CHANGE 10.00
s-0 o LICENSED CONTRACTORS DECLARATION C
a L,U 1 hereby affirm that I am licensed under provisions of Chapter 9 ANCE DATE
N a y (commencing with Section 7000)Of Division 3 of the Business and BL CT. PLG. MECH.
H y Z Professions Ccdco my license is in full fore andeffect�� ❑ ❑
zom License Class Lia Numbetl�7
Es
A
A L E Dale a-g/-g y/ Contractor -
a
BUILDING PERMIT=";' "
¢ ¢ w ¢
OWNER-BUILDER D17CLARATION "A"' "•
odU MISC.- REFER TO ORD �INFOPMATI`ON% ,•'(
A.
; N 1 hereby affirm that I am exempt from the Contractor's License
wo¢ Law for the followingreason.(Sec.7031.5,Business and Professions pERMIT ISSUANCE 6.00 A S/FT.
r -mom Code:Any city or county which requires a permit to construct,alter, 3e3 oo o-"
¢ ¢Q o improve,demolish•or repair any structure,prior to its issuance,also ELEC.CONTR. - LIC.NO. ELEC.
n am c LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w m he is licensed pursuant to the provisions of the Contractor's License
r z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe ' 0��/C 4.,D 4-
a Business and Professions Code)or that he is exempt therefrom and OTV.- t "'�'PLUMBINGPERMIT s '' „ F,EE' N
s r$ the basis for the alleged exemption.Any violation of Section 7031.5 i
ST"""ORIES TYPE CONS
by any applicant for a permit subjects the applicant too Civil Penalty ALTER-DRAIN -WATER (EA.) 4.00
y.
of not more than five hundred dollars($500).): / r
❑ 1,as owner of 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 salt (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 8�•
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 - 4.00 SQ.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- a
ments are not intended or offered for sale if.however,the.biilding GAS-EA.SYSTEM-11 4.00 It
tjOd PBA
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 PB Omer
prove for purpose of.],,). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
send Professions Code:The Contractor's Licedse Law docs not apply 3a ./,-�
• to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 6 r O
contracts for such Projects with a corumclnds)licensed pursuant 10 SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ I am exempt under Sec..,BAP.C.for this WATER HEATER W/VENT 4.00
.,on
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC,FILE NO.
WORK FRS'COMPENSATION DECLARATION WATER TREATING EQUIP. '• 4.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO:
or a certificate of Workers'Compensation Insurance;or a certified ,{
copy the
Policy rco (Sec .).:••.L,.y •S 9/� h"'��3'
N -J-kE d
Q ❑ Certified copy is hereby furnished. _ " FIRE SPRINK ENERGY T-24
7� ❑ Certifie ca y is filed with ose,citsy�inspection division. MISC. J REFER TO ORD. y❑ N❑ v ❑ N❑
QJ
Applicant C_�p(/-�L[eC�LrL/ -.-- _ .
CC W CERTIFICATE OF EXEMPTION FROM WORKERS, PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE: PLG..CONTH. LIC.NO. "PLG. Y❑ N❑ v❑ N❑
CL O (1 his section need not be completed if the permit is for one TOTAL
Z hundred dollars(5100)or less.) dvs' i� - ka «, ¢ . ye 1 „, . I• P +1a * ak°Kti-s'"'-' -
U O I certify that in the Performance of the work for which this per V P MECHANICALLL�RMITb ' €'$FaEEly x ++•'!?';FEE SUMMAR�,V
LL.F mil is issued,I shall not employ any person in any manner so as to sti1 ,t a xh s,
O W, becornsubtect to the Workers''Compensation Laws of California, - BUILDING p
Uate APPIICant ALTER OR ADD TO MECH. 4.00
} En NOTICE 10 APPLICANT: If.after making this Certificate of Iix-
F ? emption,you should became subject to the Workers'Compensation APPLIANCE' 4.00 PLAN CHECK �.
provisions of the Labor Code, you must forthwith comply with FEE 'S QK7 300
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO lomc F.M.) 3.00
CONSTRUCTION L17NDING AGENCY . AIRHANDLINGUNIT(OVER IQOOOC.EM.) 5.00 SEISMIC FEE A31
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.). _ HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.P.50 ELECTRIC
Lender's Address -
1 certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
PLUMBING"
information is correct.I agree to comply with all city and county
• 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 BTU(SEE FEE SCH. MECHANICAL
above-mentioned property lot
inspection purposes. "
(We) agree to save, indemnify and keep harmless the City of MISC. REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in way accrue again said CiE in consequence of the
m
gnti of his peril MECH.CONT. LIC.NO. MECH. .
TOTAL TOTAL 96�
Si are of titan Contra r Date! '
OFFICE COPY.