7170 APPLICANT TO FILL IN INWWMATION WITHIN RED LINES - US LL POINT.PEN ONLY
BUILDING PROJECT IDENTI FI ION PERMIT NUMBER
BUILDING - •APPLICATICSN &-PFy`RMIT w O
ADDRESS I
ID�OOONf D2 rry'Za BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
OWNER'S CHECK VALIDATION
v
N�t4OaOq^� DTY'J' A 'P' -EL'ECTRIC PERMIT "� "-- FEEy
PHONE '
CONTRACTORS `' OUTLETS-SWITCHES RECEP 5.00/1.00
Y� _ ua�No.� IGHTING FIXTURES 5.00I7.00 "
CONTAACTOR'S PPLIANCES•RESIDENTIAL 4.00
ADDRESS I (G/�1����/����A T '
�/ x�tE24%I• PHONE �V PANELS S.00 �Y DATE OF APPLICATION
ARCHITECT SIGNS B00 PLAN CHECK FEE P.C.NO.
OR
EN EER
uc.No. SIGNS TRANS. AeP^tt 3.00
ARCH.OR G.nOO mom n,.., SPECIAL CIRCUIT 5j•00 PERMIT VALIDATION
ApORE55 C,, •�'U""`'Y^"1
LU TEMP.METER OR LE INS' Jq(Jq15.G0 �1
APPLICANT'S• -I G 1�� r-, MOTORS SEE FEE SCH.
ADDRESS �,,.s�Al�J J
M*VAAW P\ MM C14 SERVICE CHANGECitV nf CLInpB/(�,S
I—o o LICENSED CON TRACTORS DECLARATION
u I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
.<A aa
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT.I PLG. I MECH.
H m z Professions Code, d 1¢y license is in full farce alldNf z �� -_ ❑ ® ❑
Z D a - License Cl V Lie.Number
g y H w Uate—�Cuntruclur
¢ a re < r El
T BUIhDINQ`PERMIT-.
¢ 0 w ¢ OWNER-BUILDER DECLARATION - INFORMA^T,IONi.
woao MISC.— REFER TO ORD -
g LL G I hereby al firm that 1 ren exempt from the Contractor's s License _ VALUATION $/FT.
FLLNj Law for the followingreason.(Sec.7031.5,lousiness and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to cons(R¢(•alter,
n,p¢2O Improve,demolish,or repair any structure'.prior t0 Its Issuance,also ELED.CONTR. _ LIC.NO. ELEC r �
A wo LL requires the applicant for such permit to file a signed statement that TOTA PERMIT TO
m he is licensed pursuant to the provisions of the Contractor's License
HiQ
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe 6YEG7
i 4 o Business and Professions Code)or that heis exempt thercfrom and QTY. PLUMBING PERMIT FEE
M H m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i; - by any applicant for a permit subjects theapplicant toachil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
(Got more than five hundred dollars($500).1:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 Oce.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to on owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP, 4.00 SO.FT FLOOR AREA TOTAL ACREAGE
himself or through his own employees•provided that such improve-
mentsamnotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-11NC.4 OUTLETS 4.00
of improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im. RES IND CON PB Golan,
for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00. '
O I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and ProfessionsCode:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.). '1.00
contracts for such projects with n contractorls)licensed pursuant to
We Contractor's License Law.' SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sea ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
'Owner Dale WATER SYSTEM 4.00 Acc.DATE ACG FILE NO.
WORKERS'COMPENSAT10N DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certil'icata nfcousent to SCINnwre. ZONING ENG.SITE NO.
or a certificate of Workers'Compansalion Insurance,or a cerlil red
copy them of(SC-.�3�$f 1OO,Lab.C.).; C sG
Policy No $7Qdinpony�
O ❑ Certified copy is icreby fur nRlffit FIRESPRINK ENERGY T-24
Zo y; Certified L„_oqg rs_(Ilw"Ih the,city 'ns ec'o i 'si n. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
Ms licanl•�IG14/.LrM V N V N
cc CERTIFICA'.rE OP EXEMPTION PROM WORKERS, PERMIT ISSUANCE, 6.00 FLOOD ZONE A.L.U.c.
LU 5 ' COMPENSATION INSURANCE PLG.CONTR. - LIC.NO. PLG.
(L O (Ibis section need not he Completed if the permit is for one TOTAL Y❑ N❑ Y❑ N
U 2 hundred dollars IS 100)or less.) 's^.✓'-
U O 1 certify that in the performance of the work for which this per, 'QTiYl a1 H NIECHANIEALA PERMIBIyr +^r i'FEE :'F,EE{SUMMRVf
LL F roll is issued,I shall not employ any person in any manner so as to J
U become subject to the Workers'Compensation Laws of California.
U 0. Dam Applicant ALTER OR ADD TO MECH. 4,00 BUILDING
} m NOTICE TO APPLICANT: If,after making this Certificate ofiEx.
F-. Z emp(ion'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(his permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.N0 3.00
CONST RUCTION LENDING AG17NCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of(lie work for which this permit is issued(See. MICROFILM
3097,CIv.CJ. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.17.50 ELECTRIC �p�46
Lender's Address -
I certify that I have read this application and state that Ilse above VENTILATION FAN (SINGLE) 3.00
information is correCL I agree to comply with all city and county PLUMBING
ordinances and state laws'relating to building Construction, and BOILER-COMP I3 H.P.Dr 100,000B.T.U.) 4.00
hereby authorise representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEESCHMECHANICAL
above-mentioned property for inspection purposes.
(We) agree to Save, milenmify and keep harmless the City of MISC.- REFER TO ORD
Cupertino against liabilities,judgments•costs and expenses which PERMIT ISSUANCE 3.00FCONST.TAX
may in any way accrue against said City in consequence of the _
grant' gas this pc tit. MECH.CONT. LIC.NO. MEG.
L TOTAL TOTAL
S arc f A p an onlrac or Data IJ
` OFFICE COPY