6282 w APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
AoDRESS 6282
/� 9 �1'- a BUILDING-,ELECTRICAL-PLUMBING-MECHANICAL
OWN IT 1 LG l/r�+� )-G } i
ry PLAN CHECK VALIDATION
�� /�� .�(� TV? &i - ELECTRIC PERMIT i FEE
(� PHONE �'J
EnacrDRs
NAM 0/p q7 UTLETS-SWITCHES-PIECED 5.00/1.00
Yp 11 rr ''r'�
ctwo (//��LrLtr UC,NO' - ILIGHTING FIXTURES 5.00/1.00
CONTRACTOR'5 (' PPLIANCES-RESIDENTIAL- 4.00
R&BD ST PHDrvE I PANELS 5.00 W DATE OF APPLICATION
OR HIHECT SIGNS B.00 PLAN CHECK FEE .C.NO.
ENGINEER
LIc.No. SIGNS TRANS. 3.00ARCH.OR '
ADDRESS ENL. _ _ SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
aPPucarvrs MOTORS SEE FEE SCH.
DREss �nj T� CC
/2,go V 7- I 94 64PA SERVICE CHANGE 10.00
o o - LICENSED CONTRACTORS DECLARATION Q r
a z u. 19mreby affirm that I am licensed under provisions of Chapter 9 - ISSUANCE DATE
a A (commencing with Section 7000)of Division 3 of the Business and SLOG. ELECT. PLG. MECH.
� D z Professions Cody;aBu license is in full force pp �f(at I zi ❑ .❑ ❑
G Lcensq Cpss Lis.Number Y�/`
H _ H,J Dime-b/34 F�,/ar-_Contractor (.
¢ a w a OWNER-BUILDER UECLARA'I'ION city OI Cupertino BUILDING PERMIT," T
o a O ' INFORMATION 'TM
E:
3 Bo- I hereby affirm that I am exempt from line Contractor's License MISC.- REFER TO ORD
eu a IL, Law for the following reason.(Sec.7031.5,Business., Professions PERMIT ISSUANCE VALUATION $/FT.
Code:Any city or county which requires x permit fact alleq �Q
E
improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTfl. LIC.NO. TEL /('��W
i w m LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
io Business and Professions Code)or Thal he is exempt therefrom and OTY: PLUMBING PERMIT FEE'
¢ H$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a3 �
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
.four more than five hundred dollars($500).1:
❑ I,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 ProfessionsDRAINS-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 sa PT FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SVSTEM-1 4.00
mems are not intended or offered for sale.If,however,the building
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 buiden of proving that he did not build or im-
RES IND CON PR Omar
prove for purpose of sole.). h INDUSTRIAL WASTE INTER. 20.00
❑ 1.el as owner of the property,he exclusively ro044, u with - ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.71744,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
to Professions Code:The who
buildsContractor's License Law dues not apply
to tr owner of properly who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts far such projects with a contractoAs)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200tt/8.00 TRACT NO. PARCEL NO.
'
❑ I am exempt under Sec.-.B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
woRKl:Rscomrl: nl'fp„NINK!?RnnoN ' WATER TREATING EQUIP. 4.00
I hereby atfi m tha) Ilcerh e e of consent In self-insure, ZONING
or a certificate oo/l��Wer 11## ������iii.1pensation Insurance,or a certified ENG.SITE NO.
copy therer(R*4 0 Lab C.). .�• 'sll f //_Af/t
Policy No, Company 'yK J 17/V rr
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z 6( Certified co is red, ipsl p1 ..ttttm r,1(y inspection division.
Q A plicant G ! L/sG MISC.- REFER TO ORD, Y❑ N❑ Y❑ N❑
CC H CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 8.00 FLOOD ZONE- A.L.U.C.
PLG, Y❑ N❑
LLQ COMPENSATION INSURANCE: PLG.CONTR. LIC.NO. ❑ NE]
Z 1'fhis section need not be completed if the permit is for one TOTAL v
hundred dollars 1$100)or less.) -
U O 1 certify that in the performance of the work for which this per OTY: , MECHANICAL PERMIT,
_ FEE FEE SUMMAR�Yr i^ j�
LL, I- mit is issued,I shall not employ any person in any intoner so as to ,
Ow become subject to the Workers''Compensation Laws of California. BUILDING
a Date Applicant ALTER OR ADD TO MECH. 4.00
} m NOTICE TO APPLICANT: 11,after making this Certificate of fix-
2 caption,you should become subject to the Worker%Compensmkm 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 10J=CF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
1 hereby affirm that,there is a construction lending agency for EXHAUST HOOD IWITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L A��• HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lenders Name HEATING UNIT(OVER 100,000 B.T.U. .50 -
Lender'sAddress 17ELECTRIC'
I Certify 111.1 I have read flus appikaticn and Stale that the B1,OVC VENTILATION FAN (SINGLE) 3.00
infonnalion is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and
BOILER-COMP(3 H.P.or IO0,000B.T.U.) 4.00
hereby authorize representatives of this city N enter upon the BAILER-COMP (Over 100,000 BTUI SEE FEE SCH: MECHANICAL
above inentioned property for inspection purposes.
1 (We) agre to save, indemnify and eep bar ess the City of MISC.- REFER TO ORD.
Cupertino
ape in a a6 y IiabiliY dg u d costs m expens s which CONST.TAX
may in ony By ii a nst said .ity in sequcn a of the PERMIT ISSUANCE 3.00
BOB of[I ermiL / MECH.CONT. LIC.NO. MECH. .
�✓ � j TOTAL TOTAL
Signatu o Applies o actor Date
OFFICE COPY