6874 PNFPLICANT TO FILL IN INFORMATION WITHIN'RED LINES= USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION - PERMIT NUMBER
ADDADILDIxG APPLICATION & PERMIT _IST 6874
IL ss
Mc/ 41 mw- BUILDING; ELECTRICICL-PLUMBING-MECHANICAL
OwrvER's /���6 y�y� *'{� " PLAN CHECK VALIDATION
NAME W'�r/�VL/ - pTV',;.ir r„ELI ECTRIC,S.PERMIT a' rKLFEE ..
VHONE • .�-
NAME ncTCRs UTLETS-SWITCHES-RECEP 5.00/100
uc.x LIGHTING FIXTURES- 5.00/1.00
CONTRACT91UOR'S PPLIANCES-RESIDENTIAL 4.00
; DRESS
o art PANELS 5.00 DATE OF APPLICATION
oe ° . SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO, SIGNS TRANS. 3.00
ARCH OR ENG. SPECIAL CIRCUIT 5.00 _ PERMIT VALIDATION
AESSv
jlp EMP'M ETER OR POLE INS. 15.00 c
APPLICANT'S MOTORS SEE FEE SCH. J
ADDRESS
SERVICE CHANGE 10.00 1�0. �����
a o LICENSED CONTRACTORS DECLARATION PAlb
a o�u: I hereby al'fom that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w c o`i (commencing with Section 7000)of Division 3 of the Business and984 BLDG. ELECT. PLG. MECIEL
r D z Professions ro,�.. ,nd my license is.in full force and effect: ❑ ❑ ❑ ❑
Z 2 w o Lieenx Cla 51s1_Lie.NREDIT
w
Urate ire Comraato�_ City Of Cupertino »,uBUILDING PERMIT
Q w OWNER-BUILDER DECLARATION /+"%;IN„F, ._ �N
w 3 LL r 1 herebyaffirm that I am exempt from the Contractor's License MISC.- REFER TO ORD - -
p VALUATION - SIFT.
F u o¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a Permit to construct,alter2 to ,
pp
Q FO improve,demolish,or repair any structure,prior to its issuance,also ELEC.C-ON_T-fl.` LIC.NO. ELEC. / !t ODA
i DLL requires the applicant for such permit to file a signed statement that � �- TOTAL // PERMIT TO
X $ he is licensed pursuant to the provisions of the Contractor's License
i Law(Chap(er9(commencing with Section 7000)of Division 3 ofthe r �'wll7�M-
a Business and Professions Cade)or that he is exempt therefrom and OTY.s i.- Y .f PLUMB PERMIT; 4IFEE� L
M r-$ the basis for the alleged exemption.Any violation of Section 7031.5 '` a STORIES TVP CONSTR.
s ;_ by any applicant for a permit subjects the applicant to IT civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than Ove hundred dolldrs($500).1:
❑ 1,as owner of the property,or my employees with wages as
BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will,do the work,and the structure is not -
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOORAREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
mentsare not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.)' 1.00 BUILDING USE
builder will,have the-burden of proving that he did not build or im- RES IND CON Pe Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 1 Ag ESSORSPARCEL NO.
and Professions Lode:The Contractor's License Law does not apply
to an owner of property who builds or improves(hereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1,00
contracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
❑ I am exempt under See. ,B'.d1P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.OATE ACC.FILE NO.
WORKIiRs'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that 1 have a certificate of consent to sei6insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insumnce,'or a certified
copy thereof f$ee 00,Com ab.C.j� - -
PolicyCcrl Compan/SIT-lTTl�fj 11� -
C] ❑ CerlitleJ copy is hereby ltshed. it FIRE SPRINK ENERGY T-24
Z Z -,d cony-is fl it l he city inspection Division. MISC.- REFER TO ORD.
Applican! ,. - Y [] N� V [] N[]
CC !2PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
� > CER'I'I FICATE F EXEMPTION FROM WORKERS'
UJ _ COMPP.NSATION INSURANCE PLG.CONTR. UC.NO. PLG, v 0 N� 'Y� N❑
d o (This section need not be completed if the permit is for one TOTAL
U Z hundred dollars IS IOD)or less.) - _ T'°' °
U O - I certify that in the performance of the work for which this per, DTV. MECHANICAL'i,PERMIT N' FEE 3.t x. lug�tF�E SUM,,
LL F mills Issued I shall not empl y any person In any manner so as to ) +h. ,p 3 ,�h y„ �a 4 K d&
O w become subject to Lire Worke Co mutt n aw of Calnor w v
Date Applicanrty�q.�1� ALTER OR ADD TO MECH 4.00 BUILDING ..�(f`
} ED NOI ICE TO APPLICANII,If,Mtcr making II-s rbGca',of 'x-
F ? emption,you should beccmasubject to the Workers'CompensUtmm APPLIANCE 4.00 PLAN CHECK •1 i---01
provisions of the Labor Code, you must fotlhwilh comply with FEE o4d
U such provisions or this permit ihall be deemed revoked. AIR HANDLING UNIT(TO 10,000 C.F.M) 3.00 ,3
CONSTRUCTION LENDING AGENCY AIR HANDLING IT( V 10 C:F;M.) 5.00 . SEISMIC FEE e�
1 hereby affirm that there is a construction'lending agency for EXHAUST HOO ( TH DUC )V 2.00
the performance of the work for which this permit is issued(Sec. HEATING UNIT r a .1 4.001MICROFILM
3097,Civ.C.).
Lender'sN., �bA� HEATING LIN ER100, 0001-1.17.50 ELECTRIC
Lender's Address
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
h fon nation is correct.1 agree to comply with all city and county PLUMBING
1 ordinances and state laws relating to building construction, and BOILER-COW(3 H.P.or 100,000 B.T.U.) 4.00
r hereby authorize representatives of this city to enter upon the - g01 LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL /y
above-mentioned property for inspection purposes.
(We) agree to Save, indemnify and keep harmless the City of MISC..- 'REFER TO ORD.
Cdpertin against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in a way accrue against said City in consequent of the
g..t,.nrpf is permit. MECH.CONT. LIC.NO. MECH. O l
TOTAL �S
1��$ QC �. �� TOTALt
- Sigmlureof ppll rat ntmctor Date
OFFICE COPY