6027 AWLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING - APPLICATION & PERMIT ^n
ADOREss BUILDING-ELECTRICAL-PLUMBING-MECHANICAL_ 3 G
OWNER'S PLAN CHECK VALIDATION NAME DTV. ELECTRIC PERMIT FEE
-D PHONES I'�Y
NAMERAcrons ip LITE
ETS-SWITCHES-RECEP 5.00/1.00
/'VC LIc.ND. Al( LIGHTING FIXTURES 5.00/1.00
noucACTOR S
sDRS PPLIANCES-RESIDENTIAL 4.00
HONE •B PANELS 5.00 DATE OF APPLICATION
ARCHITECT I PLAN CHECK FEE P,C.NO.
oR SIGNS 6.00
ENGINEER
LIC.No, SIGNS TRANS. 3.00
ARCH,OR
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. A, 15.00 rx
APPLICANT s r/IT(/
ADDRESSODREss MOTORS SCH. yLJ
SERVICE CHANGE 10.00
F o FoF LICENSE:[)CONTRACTORS DECLARATION _
rt Z U I hereby nfMn that I am licensed under provisions of Chapter 9 2z 0�!L ISSUANCE DATE
(commencing with Section 7000)of Division 3 ul the Rosiness and of CU
BLDG. ELECT. PLG. MECH.
r m'EA Professions Codw C�yyd my license is in full turec and effect
License Class_/.7 Lic.Number 7/17
o F w DateContrac for _
Ic tc w OWNIi R-BUILDER DECLARATION BUILDING PERMIT
A.
°;LL y 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD OR ON
F L o a Law for the following reason.(Sec.703 LS,Business and Pru14ssions PERMIT ISSUANCE 6.00 ION
my Code:Any city or county which requires a permit to construct,alter,
Q 40 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. 'o
a wD¢ requires the applicant for such permit ID file a signed stalamene that TOTAL e?f9 `
he is licensed pursuant to the provisions of the Contractor's License 1�FP'dra L��
P F Z > Busi(Chapter and
professions
Code)or Section d0exempt ivision 3 of thu
q o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
I- the basis for the alleged exemption.Any violation of Sect ion 7031.5
a 3 by any applicant for A permit subjects the applicant to a civil penalty' STORIES TYPE CONSTR.
ALTER-DRAIN (EA.)
of not more than five hundred delta.($500f):
D o as owner at the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will(S the work,and the structure is not
intended or offered for sale(Sec. doe nosiness and Professions. DRAINS-FLOOR,ROOF,AREA,COND. 4.00
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
himself or through his own employees,provided that such improve. -
mmTtSarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS,EA.SYSTEM-OVER 4(EA.) 7,00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for 1,aso neeose of sale.). RES INDUSTRIAL WASTE INTER. 20.00 ❑ 1� ❑N ❑ Other❑
❑ d as owner of the property,he exclusively contracting with
licensed ssions contractors to construct the project(Sec. does Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORSPARCEL NO.
and Professions Code:The Convactor'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 a contractor(%)licensed pursuant to
the C'ontractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under SCc. ,B.&P.C.for this WATER HE
reason ATER W/VENT 4.00
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORSE RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm But I have a certificate of-consent to self-inmre.
or a certificate of Workers Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(See.3800,Lab.C.).
Policy No. Company
❑ Certified copy is hereby furnished.
z ❑ Certified copy is fled with the city inspection division. FIRE SPRINK ENERGY T-24
F 4Applicant MISC- _ REFER TO ORD, vQ NEI v � N�
w CER1]FICA'1'1;OF 17XFMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE AL U.C.
W > COMPFNSATION INSURANCE PLG.CONTR. LIC.N0. PLG
CL O 1This action need not be completed if the permit is for one TOTAL Y❑ N� Y N[
Z hundred dollars(SI00)or less.)
U O 1 certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any magnet so as to
O w hecom gblee�,tto.tlte Worker u,Co sati n laws�. .. ....a.
n D°t`� 3jY-ApplT I e-.�H. o ALTER OR ADD TO MECH. 4.00 BUILDING ���,S`d
} Z NOTICIi O A I'LICANT: IL/atter making this C rtifieate of Fx-
_ mmPtmL you should became subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith Comply Will, _
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10)000C.F .) 3.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER M.) S.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097.CiYC). HEATING UNIT(TO OB. 4.00
Lender's Name ^y /
Lender's Address H EATI N G UN IT(OV ER 100,000 B.T.0 I ELECTRIC K O O�Ir
I certify that I have read this application and state final the above VENTILATION FAN ISQ .00
in ordinanOrin ces
a s correct I agree to comply with all cityland county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws .clueing m is building constnmtion, and
hereby aWhorizc roperty for ins ec this rp eu cnenrupon the
above-mentioned property for inspection purposes, BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL �
(We) agree to save, indemnify and keep harmless the City of MISC.: REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00 '3V r4
granti (this permit , MECH.CONT. LIC.NO. MECH.
S- -. TOTAL ds! TOTAL [ 7'�
S�n tore of Applicant/C tractor Uale �� / J
OFFICE COPY