6939 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT PERMIT NUMBER
BUILDINGAOORE55pow Oak C�-. _ __ _ _ _ 6939
W kBUILIDING—ELECTRICAL—PLUMBING—MECHANICAL
uWNEH S PLAN CHECK VALIDATION
`N`Ak`E �L 99b-839
WI�• �IEIt:. ELECTRIC PERMIT FEE
PHONE
CONTERIP�TOR'S UTLETS-SWITCHES-RECEP 5.00/1.00
uc.rvo LIGHTING FIXTURES 5.00/1.00
AcroRs
coNTR /—�p1�j S PPLIANCES-RESIDENTIAL 4.00
A
CONTRACTORS
lU O J
PHONEAl PANELS 5.00 DATE OF APPLICATION
OR
SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO, SIGNSTRANS. 3.00
ADOR'ESR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
z" ITEMP.METER OR POLE INS. 15.00
APPLICANTS -
ADDRESS MOTORS SEE FEE SCH. 9
SERVICECHANGE 10.00
02 LICENSED CON'I'RACfORS DECLARATION /
<v u I herebyaffirm that 1 am licensed under VISIOnsof Cha ter9
2 w pro s ISSUANCE DATE
(commencing with Section 71Xse of fall fon 3 of the Business and
G a- SLOG. ELECT. PLG. MECH.
F 2 x Professions Cale J cense is in full B
z O'v1 Or Dutc <• Iasyi� Lic.Num r El E 0 (
oN w Dateyj=ll' n —Contractor
a r< s
¢ ¢ OWNER-tl UILUIiR UECLARA'I'ION BUILDING PERMIT
A o a g INFORMATION
X ; N I hereby affirm that I so exempt from the i Contractor's License
ssions MISC.— REFER TO ORD
Fuoa Law for the following reason. 7011.5,tlusinessand Professions PERMIT ISSUANCE 6W VALUATION
Code:Any city or county which reyuiresu Isemrit toe...trucL.Ileq
¢ rt ¢ 0 improve,demolish,or repair any structure,prior m its issuance,also ELEC.CONTE. LIC.NO. ELEC.
O, requires lire applicant for such pemlil to Glc a signed statement that ,TOTAL PE O
d w$ he is licensed pursuant to the provisions of the Contractor's License - I
HiQ Law,(Chapter 9(commencing with Section 7000)of Division 3uflhe
1 i o Busirm and Profssiore Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
EE r the basis for the alleged exemption.Any violalion ofsection 7031.5 STORIES TYPE CONSTR.
e. by any applicant For a Permit subjects the upplic.m ma civil pe,,airy
of not more than five hundred dollars(SSDOL): - ALTER-DRAIN -WATER (EA.) 4.00
❑ I,us owner of the property,or my employees with wags as BACK FLOW PROTECT.DEVICE Z.00 DEC.GROUP RES.UNITS
sole comperr ation,will do the work,and the structure Is not
intended or offered for SAIL(Sec. 7044, Business and professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:'rhe Contractors License Law doe not apply to as owner of
property who builds or improve thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
s� himself or through his own employcee,provided that such anprove-
mentsamnot intended oroffered for Sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00 ,
r 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 he did not build or hn-
provefoTPurposeofsaICT. INDUSTRIAL WASTE INTER. 2000 RES IND CON PB Ome,
O I,as owner of the properly,am exclusively contracting with ❑ ❑ ❑ D ❑
licensed conlrazlors to construe the Project(See.7144,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Calc:The Contractor's License Law does not apply
to an owner of properly who builds or improve thcoam,and who LAWN SPRINKLERS-OVER 5(EA.) 1,00
contracts for such projects with a contractor s)licensed pursuant to
the Contmctur'e License law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I um exempt under Sec, IT&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK FRS'COM P17NSAIION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that 1 have a certificate of consent to self-insane. ZONING ENG.SITE NO.
or certificate of Workers�'s�Cr mpom(u�rti__on Insuran or a certified
I'nl , Nm4.7�161➢J� 1
Z ❑�ertrfrcd ropy u hereby furmshN.
Z 2 LT t.crry ily inipLt'hon Jiviv FIRE BPRINK ENERGY T]e
F O Applicam�t (�1�a1 t11Lr MISC.- REFER TO ORD. Yo NL Y ❑ NEI
m PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.C.
� CI!RTII9CATIi OF EXEMPT ION FROM WORKERS'
LU C04ENSATION INSURANCE PLG.CONTR. LIC.NO, PLG. Y❑ N Y N
CL 0 ('Ibis lection Died IT I he compkled if the permit is for o TOTAL
hundred dull...(S 100)oT Ips.) m
U O I certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
IL U 'mil is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
Q. D.m Applmanr ALTER OR ADD TO.MECH. 4.00 BUILDING
} ro NO'T'ICE TO APPLICANT: If,after making this Certificate of Ex-
F 2 emplion,you should become subject to the Workeri Compensation APPLIANCE 4.00 PLAN CHECK
provisions of lire labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C-F.M.) 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER IOAODC.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there K 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.C.L HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lerseri Name , HEATING UNIT 100,000 B.T.U.P.50
Lender's Nan I. ELECTRIC
I certily that I have read this application and slam that the above VENTILATION FAN (SINGLE) 3.D0
information Is correct. 1 agree to comply with all city and county PLUMBING
ordinances and slate laws relating to building construction, and BOILER-COUP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize rcprecnlntives of this city to enter upon the
aBOILER-COMP ( vert 000STU)SEEFEESCH. ,MECHANICAL 7✓
bove entioned property forinspection milw.s.
(We) agree to vve, indemnify and keep harmless the City of I REFER TO ORD.
Cupertino against liabilitie,judgments, costs and ezpensa which
may in any way accrue against said City in consequence of the P IT ISSU N E 3 DO CONST.TAX
g of[his pen MECH.CONT. LIC.NO. E
1 1�1 �'%m^a..y,'lf^, TOTAL TOTAL
lure of Applicant/Contract
I r ate ' �'t11n�7- x./a�-sL)J,v
OFFICECOPY