6963 `APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
` BU I LDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS --1
/ L- �'/W I✓G BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 6963
OWNER'S
' NAME ' PLAN CHECK VALIDATION
��jf� r/ //� (�/'�✓/ DTV. ELECTRIC PERMIT FEE
CONTRACTOR
N �J� OUTLETS-SWITCHES-RECEP 5.00/1.00
171" LC.NO. LIGHTING FIXTURES 5.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
AD2oGS5 s/fa�y' /6 SSS
PRONE' 1 PANELS 5.00 DATE OF APPLICATION
ARRCHITECi SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.ND, SIGNS TRANS. 3.00 '
ARCH.OR ENG, SPECIAL CIRCUIT S.DD PERMIT VALIDATION
zm TEMP.METER OR POLE INS. 15.00
ASMOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
o ¢
o
Fo LICENSED CON'I'RACI'ORS DECLARATION J _
Fi W I hereby affront that I am licensed tinder provisions of Chapter 9 ( ISSUANCE DATE
a w (commencing with Section 7000)of Division 3 of the Business anJ
BLDG. ELECT. PLG. MECH.
E H z Professions Cod, an yL se is in full lurceyeyL�Jfp9 ❑ ❑ ❑ ❑
z o m - License••Cflu�cs, -Jr _LIC.Number�LO Z
y F
1)ate 18/_ Contractor
Q Y J BUILDING PERMIT
Be ¢w OWNER-BUILDER DECLARATION INFORMATION
a'xr ;LL w I hereby affirm that I an exempt from life Contractor's License MISC.- REFER TO ORD
VALUATION
u o j Law for the following reason.)Sec.7031.5,Business and Professions 6.00 /FT
r - PERMIT ISSUANCE J r
Code:Any city m county which structure purine o is issuance.
alter,
R ¢ ¢ 20 improve,demolish,or repair any structure,prior to its¢nuance,also ELEC.GDNTfl, UC.NO. ELEC. /
so
O¢ requires the applicant for such permit to file a signed statement that TOTAL _
n w m" he is licensed pursuant to the provisions of the Contractor's License O_ PERMIT TO
F z a Law(Chapter 9(commencing with Section 7000)of Division 3 of the
4 O Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE fs�L RQQ�
¢ f m the basis for the alleged exemption.Any violation of Section 7031.5 I /STORIES I TV�P CONSTR.
P. 3 _ by anyotmor the for aperdredBOND;($5 0R.) amtoacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00 /frC�d,
of not more chin five hundred dollars ts the ap.1:
❑ 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE
their sole cmnpensation,will do the work,and the structure is not 2.00 (�ft�l l l r OCCy GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and ProfessionsDRAINS-FLOOR,ROOF,AREA,COND. 4.00 [')-'r
Code:The Contractor's License Law docs 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
,. himselfor through his own cmployels,provided that such Improve-
ments are not intended or offered for sale.l L however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM OVER 4(EA)
builder will have file burden(if proving that h . - .
e did not build or im- 1.00 BUILDING USE
prove 1,as owner
of sale.). RES INDUSTRIAL WASTE INTER. 20.00 El El
❑N ❑ Other❑
❑ Las wmer er of the property,am exclusively contracting with
licensed contracmrs to construct the project(Sec. 7144,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:1'he Contractor's License Law does not apply
to an owner of property whir builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1,00
contracts for such projects with a contmetoRs)licensed pursuant to
the Contramor License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,B.&P,C,for this
calm WATER HEATER W/VENT q-Op
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK FRS'COMPENSA'I'ION-DECLARA'f1ON WATER TREATING EQUIP. 4.00
1 hereby alfirm that I have a certificate of consent to self-insure,
or a certifivatc of Workeri Compensation Insurance,or v certified ZONING ENG.SITE NO.
copy thereof(Sec 3800,Lah.C.).
Policy No. Company
O ❑ Certilietltopynhe¢byfumirhed. RE SPRINK ENERGY T-24z Z ❑ Certified copy is filed with the city inspection division.
F• O Applicant MISC.- REFER TO ORD. Y[] NY0 NE)
it T CFR1'IFICA'I'E OP EXIAVIAON FROM WORKERS' PERMIT ISSUANCE 6.00 FLOODZONE A.L.U.C.
IL > COAIPBNSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL z ('this section
rerled not be completed if the permit is for one TOTAL Y C] NF] Y NEI
0 2 hundddolWs(5100)ror less.)
U O I certify that in the perfoneance of the work for whirl,this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil is issued,1 shall not employ dry n in any manner so as to
Q hecumyf ) t,,tp.the Workers' omp yah' o i.
U y Datn!_ J-P SA pplicam ALTER OR ADD TO MECH. 4,00 BUILDING
} co NOl'IC:TO APPLICANT: IL after making this Certificate;of fix- / -
Z emption,you should hecome subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with U FEE such provisions er this permit shall be deemed revoked. AIR HANDLING UNIT ITO 10000C RIVAL) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVERIOPWC.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD IW ITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3017,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information n correct. I ogre to comply wi0t all city and county BOILER-COW(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and stale laws elating to building construction.opn. and
hereby authorise roperty farcies of this city to enter.upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH.
above-mentioned property for inspection purpoRs. MECHANICAL
(We) agree to rove, indemnify and keep harmless the City of MISC.'- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may any accrue against said City in consequence of the PERMIT ISSUANCE 3.00
gra mK of this permit MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL �S' °D
Sigrmt reef APED t/Contract at
OFFICE COPY