6952 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
. BUILDING PROJECT 1 DENTI FICATION PERMIT NUMBER
BUILDING /yy��s �-a APPLICATION & PERMIT
I ADDRESS �v LJI /7/'/G�'1
��/`/•r BUILDING-ELECTRICAL=PLUMBING-MECHANICAL _ 6952
OWNER'S ' • z ' ,', .- PLAN CHECK VALIDATION
NAME �le /' a
GrV/v(i Z�/jC�' OTY�t�'j{ �ELgECTRIC PERMIT
.t- ;__'= -FEE,;,„ -
• PHONE
NAVFACTOR s' UTLETS-SWITCHES-RECEP 5.00/100
/i'Yf Q(fC1`r (ruc,NO. LIGHTING FIXTURES 5.00/1.00 /
CONTRACTO y5� � ,N� �� ppL1ANCE5•RESIDENTIAL 4.00
Y f�
ADDRESS �y
e9{fy ��rj��//�{.Yf PRONE "'/1S PANELS 5.00 DATE OF APPLICATION
ARCHITECT _ SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEEP
' LIC.rao: SIGNS TRANS. - 3.00
noon Ess END. SPECIAL CIRCUIT 55,00 PERMIT VALIDATION
zip rrEMP.METER OR POLE INS. 15.00
anrucarvr�e2 MOTORS SEE FEE SCH. '
ADDRESS
h1puathwin Ow SERVICE CHANGE 10.00
a o o LICENSED CONTRACTORS DECLARATION.
1 u w 1 hereby affirm that I am licensed under provisions of Chapter 9 • ISSUANCE DATE
N (commencing with Section 7000)of Division 3 of the Business and
a c nF r BLDG. ELECT. PLG. MECH.
r i
Professions Cudeynd ylicense isN (all turn f•n
z O - License Class. 7 Cic.Numb r r 0, 1 Ell
O w F w Uate_ �I-�f Contractor -
a v .".BUIL•DINGPERMIT
¢ ¢ w a
OWNER-BUILDER DECLARATION
City
A o a ea REFER TO ORD
w ; LL w I hereby affirm that I am exempt from the Contractor's License MISC.- VALUATION _ b/FT.
u0a Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00, 44,0A0
w a Code:Any city or county which requiresa permit to 2onstruct,alter,
Q ¢ Q Q improve,demolish,Or repair any structure,Prior to Its Issuance,also E nEC.CONTR/.� LIC./NO. ELEC. l
LL requires the applicant for such permit ID File a signed stattonconf that ��j,r/D) Ef�G�YIli /%5�7i.�' TOTAL ('U PERMIT TO
a, w$ he is licensed pursuant to the provisions of the Contractor's License {/Y
Hit - Law(Chapter 9(commencing with Section 7000)ofDivision3ofthe .••
a Business and Professions Code)or shut he is exempt therefrom and QTY. I PLUMBING PERMIT FEE'
¢ _$ the basis for the alleged exemption.Any violation of$ection 7031.5 ' STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant boa civil penalty ALTER-DRAIN -WATER (EA.) 4.00
.fact more than rive hundred dollars(5500).):'
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS.
I heir 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 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 SD.FT,FLOOR AREA TOTAL ACREAGE
himselfor through his own employees,provided that such improve- .
menta arc not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-.EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that lie did not build or in,- RES IND CON Pe Other
prove for purpose of sale.). 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. 6.00 ASSESSORS PARCEL NO. -
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon;and who ILAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a comractods)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200tt/8.00 TRACT NO. Z -PARCEL NO.
❑ lam exempt under Sea ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that 1 have a certificate of consent to self-insure, ZONING ENG.SITE NO.
- or a certificate of Workers'Compensation Insurance,or a Certified
copy thereof , ,,Lah.C.). /� )
Policy Ng li npany-/'��-
O ❑ Certified copy is creby furnished. FIRE SPRINK ENERGY T-N
Z ZO ❑ Cnt-ted coy s filed with the.}i�y_jn coon division. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
Applicant��W6+1 il d tic-e 'fly Y N Y N P:
LU rn `CERTIFICATE EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
-
>_ COMPENSATION INSURANCE PLG.CONTP. LIC.NO. PLG.
CL 0 IT his scelidn need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
• Z) Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this r XbW ° "i0 'b A'FEE SUMMARY
y p pL DTV. MECHANtCACyPERMfT .z+t'.te "KF,EEr ,...�a, -..:.
LL F
mit n Issued,I shall not employ any Perron in any manner so as to ".�. m s._Ip.,Fr a; TMy7.,' i '
W become subject to the Workers'Compensalion Laws of California.
Date Applicant ALTER OR ADD TO MECH. 4,00 BUILDING
O
>.
y NOTICE TO APPLICANT: If,after taking this Certificate of fix-
F 2 emotion,you should become subject to the Workers Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code,you must forthwith Comply with. FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION L17NDING AGENCY AIR HANDLING UNIT(OVER 10000C.EM.I 5.00 SEISMIC FEE
1 hereby afinn 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(Sea MICROFILM
3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC 603 ✓�
✓
I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00 '
information is CGITCCL I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building ronstruction, and BOILER-CObF(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city Io enter upon bbe BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for 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 CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
gmntin f this pep'b. - MECH.CONT. LIC.NO. MECH.
•t •a D'A. TOTAL TOTAL.
Signature ApoficantlContractnr I Dail Cly
(
OFFICE COPY It