6093 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS _ _ _ 6293
¢° R_-T - BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
Owry ER'S c PLAN CHECK VALIDATION
1AMf f
G'^7 .�- �b1�OTY. ELECTRIC PERMIT FEE
O PHo�I"
N/AMERacTOR's , nn Ill�, UTLETS-SWITCHES-RECEP 5.00/1.00
L:J Q o 0 therof- fA Icr.N s~ LIGHTING FIXTURES 5.00/1.00
CONN
ATRacroR5 PPLIANCES-RESIDENTIAL 4.00
ss_ (( 'f l
`7 S 1114 Q 16A J ^ PI1oNE/'1 L eC� �31 J PANELS 5.00
DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
on SIGNS 6.00,
NGINEER
Llc.NO. SIGNS TRANS. 3.00
ARC HE Ss ENG, SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zm EMP.METER OR POLE INS. 15.00 -
APPLICANT
ADDRESS
MOTORS SEE FEE SCH-
A
SERVICE CHANGE 10.00 /
'ra'H'o o LICENSED CONTRACTORS DECLARATION
AX
�0/� �
<u v I hereby affirm that I am licensed under provisions of Chapter 9 Q -
N a H (mnuoencing with Section 7000)of Division 3 of the Business and ISSUANCE GATE
1- pj z Professions Coln:rtR license is in full fore ads (qL1 BLDG. ELECT. PLG. MECH.
z o w – Licens Clgss G—^�J– Lic.Number ! /•
Date/v/1E! /�E! Contracto
Ic S w ¢ OWNER-BUILDER DECLARATION BUILDING PERMIT
w- °` U MISC.- REFER TO ORD INFORMATION
; 1 hereby affirm that 1 am exempt from the Contractor's License VALUATION
LL O a Law for the following reason(Sec. uiresa permit
reconstruct,
and Professions 6.00 S/FT.
. - PERMIT ISSUANCE
Code:Any city.,county which structure permit teeensuanc,also w.w�.
¢ improve,demolish,or repair any structure,prior to its issuance,also ELEG.CONTE. LIC.NO. ELEC. v V V
u —O u requires the applicant for such permit to file a signed statement that TOTAL
ss w be is licensed pursuant to the provisions of the Contractor's License PERMIT TO
H z a Low(Chapter 9(commen<iagwith Section 7000)of Division 3 ofthe �d� ���
E 4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
(Cthe basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
sem- by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4. e
of not more than live hundred dollxrs(S500L)'.
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.OD00 C
their sole compensation,will do the work,and the structure is not OCC.G OUP RES.UNITS
intended or offered 1'or sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 4.00
Code:The Contractor's License Law does not apply to an owner of QY AJ COproperly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4200 50,FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
mentsarenotintendedoroffered 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-
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 1,00 BUILDING USE
prove for purpose cf SalcJ' INDUSTRIAL WASTE INTER. 20.00 RES' IND CON PB Omer
❑ 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 5.00 A55E55oES PARCEL No.
and Professions Code:'I'lie Contractor's License Law does riot apply V.B.
to an owner of property who builds or improves thereon,and wlw - LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractoKs)licensed pursuant to
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Seo. ,B.&P.C.for this WATER HEATER W/VENT
reason 4.00
Owner Date WATER SYSTEM 4.00
ACC.DATE ACG FILE NO.
WORK[-RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a euruficateofconsem to sel Ginsurre,
or a certificate of Workers'Compensation Insurance,or a Certified ZONING ENG.SITE N0.
'ml ( 3�Q Wh.C,.l.
krvhy
❑ CelldiiLd po yIx file famished. FIRESPRINK ENERGY T$4
Z Z Cl Certil'i wp is lited�y�� the ty ins ection division.
F O Applican ' fZL� s+'� MISC.- REFER TO ORD. - Y [:) NE -Y C] NE]
Cc Ln CERTIFICA'IIi 01'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.O.
LU > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
Q, 0 (This section need nut be completed if the permit is for one TOTAL Y[:] N❑' Y❑ NC]
U O hundred dolhu,(S100)r be
I certify that in the performance of the work for which this per-
QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner so as to
become subject to the Workers'Compenmtion Laws of California.
U a Dam Applicant ALTER OR ADD TO MECH4.00 BUILDING
>_ NO] Ii y D.Ic "f0 APPLICANT: it,alter making this Certificate of Ex. . f T
F ? cnmtien,you should become Subject to the Workeri Con.pensatiun APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=r-F.M.) 3.00 FEE
CONSTRUCTION LENDING AGENCY- ,. AIR HANDLING UNIT(OVER IO,D000F-IA) 5.00 SEISMIC FEE 3-0
I hereby affirm that 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,Cis.C.).. HEATING UNIT IT O 100,000 B.T.g
Lender's Name
Lender's Address MVENTILA�TION
UNIT(OVER 100,000 BELECTRIC
I certify that I base read thisappbcataon and stale Ulal the above FAN (SINGLE)alternation is correct. I agree to comply with all city and county PLUMBING
ordinances and statellaws relating to building construction, and (3 H.P.or 100,000 B.Thereby authorize representatives of (his city to enter upon theabove-mentioned property for inspection purposes, (Over 11X),000 BTUI SEMECHANICAL
(We) agree to Save, indemnify and keep harmless the City of REFERCupertino against liabilities,judgments, costs and expenses which CONST.TAX
may Nj ny way accrue against said City in consequence of the NCE gran" ofhispMECH.CONT. LIC.NO.el
/o y TOTAL S �D�
Signature at Applicant/Contractor D e -
OFFICE COPY