5524 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY,
AtATDI NO PROJECT I DENTI FICATION PERMIT NUMBER
A„ „G APPLICATION & PERMIT '
ADDRESS p
�Os00 /�y�'Aa1Z/} fj/.vp
BUILDING
InnBUILDING-ELECTRICAL-
PLUMBING-MECHANICA
L 5524
OWNERS
PLANCHECK VALIDATION
NAMFLr OTV. , ELECTRICPEflM1T" ,'FEE
U CNEC
CON tRACTORS - C /Q
NAME ) OUTLETS-SWITCHES-RECEP 5.00/1.00
,[S COX..) Ie�/aCJ. LIC,NO.'l33NZ6 LIGHTING FIXTURES 5.00/1.00 :.J 6,,S.
CONTRACTOR S f PPLIANCES-RESIDENTIAL 4.00
�3oA Al � �J ,• V'✓ FRONEg93-)za9 PANELS 5.00 DATE OF APPLICATION
- ARCHITECT SIGNS 6.00 PLAR-EWEE7 PC.NO,
OR
ENGINEER
LIC.,. c.NO. SIGNS TRANS. 3.00 '
ARCHESS R .00 END SPECIAL CIRCUIT 5PERMIT VALIDATION
.
ZIP TEMP.METER OR POLE INS. 15.00 n /
APPLICANT MOTORS PAIU SEE FEE SCH.
ADDRESS //
/;/L�a.4 k,Rk$) AO75 44105 SERVICE CH3a E 10.00
w o O 984
LICENSED CONTRACTORS DECLARATION
a v I hereby affirm that I am licensed under provisions of Clmpter 9 ISSUANCE DATE
Z (commencing with Section 7000)of Division 3 of the Businessand CINY ape Ino BLDG. ELECT. PLG. MECH.
" Qy'6^ Lin c.
Cor and my license is in full force nJ effect
Z o LicclMe Class [�Lic.Numbers-33� ❑ ❑ ❑
OZ Z r D Date.7//_.3 dw Contractor-L .CO
Y f 7�)ie a c�L BUILDING PERMIT,
W OWNER-BUILDER DECLA AT-ON
It
- NFORMATION
wu y I hereby affirm that I am exempt from the Contractor's License MISC. REFER TO ORD VALUATION $/FT.
F LL m j Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00
Code Any city or county which requires a permit to construct,alter,
0 improve,demolish,or repair any structure,prior hr its issuance,also E1(EC.CONTE. LIC.NO. pLL EC. �,
o u requires the applicant for such perm,to file a Signed Statement that E Cow Ce AUT 'Q PERMIT TO
o ac w m he is licensed pursuant to the provisions of the Contractor's License PPY Lr - ru VVV P
iii Law(Chupten.9(commencing with Section 7000)of Division 3o(lhe
F i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
r $ the basis for the alleged exemption.Any violation of$ection 7031.5 STORIES TYPE CONSTR.
n3 _ by any applicant for.permit subjects Ilio applicant to a civil penally ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars($500).):
❑ I,as owner Of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole c unpenseline.will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
`. himself or through his own employees,provided that such improve-
menlsam or intended or offered for sale.If,however.the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or int RES IND CON PB Omer
pro 1,as ownefor r of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑ ❑
❑ d as owner of the property,am exclusively contracting with
licensed contractors to construct the project(See.does,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The who
builds
o improv s th does not apply
toan trowner Of property buildstrimprovesthereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contmatod sl licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
C, I am exempt under Sec._,W&P.C.for this WATER HEATER W/VENT 4.00
mason
Owner Data WATER SYSTEM 4.00 - ACC.DATE ACC.FILE NO.
WORK I!RS'COM PENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a Cerlifm.tC ofc.ment to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Contpensdimn Insurance,ar a certified
copy thereof(Sec.WmIk LurLC
C.In
Policy No. Company"�N TPS�r�vuT/
I�Cenified copy is hereby fumuiled. FIRE$PRINK ENERGY T-24
Z ❑ Certl and copyis filed with OIC city inspection division. MISC.- REFER TO ORD.
O Applicant .f'/'.('A•s/SIJ C Y❑ N❑ Y N❑
Fy PERMIT ISSUANCE 6.00 FLOOD ZONE A.LLLC.
� > CIiRTII'IGATIi OF IiXEMI'TION I*ROM WORKERS'
LLI _ COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
CL O (This section need not be completed if the permit is I'or one TOTAL - Y❑ N❑ v❑ N❑
� Z hundred dollars IS 100)Or less.)
U O 1 certify that in the performance of the work for which this per- s r FEE SUMMARY !
LL F- mit is issued,I shall not employ any person in any manner So as to QTY. . .,MECHANICAL PERMIT FEE
O become subject to the Workers'Compensation Laws of California.
w Doe Applicaut ALTER OR ADD TO MECH. 4.00 BUILDING
} ED NOTICE;TO APPLICANT: If,after making this Certificate Of Ex-
? conomn,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 10PWC.F.M.) 3.00 ,
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10SMC.F.M.) 5.00 SEISMIC FEE
1 hereby affirm tint[ 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.CJ. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name - HEATING UNIT(OVER 100,000 B.T.U.17.50
,2 Lender's Address - ELECTRIC
I certify that I have read this application and slate that the above VENTILATION FAN.(SINGLE) 3.00 "
information is correct. I agree to comply with all city and county' PLUMBING
BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
ordinances and slate laws relating IG building construction, and
hereby authorize representatives of this city t0 enter upon the BOILER-COMP IOverlW.00OBTUISEEFEESCH. 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 aceto HgainsI said City in consequence of lm � PERMIT ISSUANCE 3.00
gnatum or penmi MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Si Hone f ppliciint/Comnictor e
OFFICE COPY