16643 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION 'PERMIT NUMBER,
.UILDI.G APPLICATION & PERMIT 1 C A n
LADDRESS_-r, / 4}BUILDING—ELECTRICAL—PLUMBING—MECHANICALR � e'� PLAN CHECK VALIDATION
DTV. ELECTRIC PERMIT FEE/
,•' NAM>EHAcroRs UTLETS-SWITCHES-RECEP 10.00/1.00
6r3',6'S OPAIS,-R.11VC ua,No S7 21 Yr LIGHTING FIXTURES 10.00/1.00
f- TORS
ADOREss /J'//j SJR PLIANCES-RESIDENTIAL 4,00 ^
/- 1 CJ PHO. �/� PQ $ .00 PATE OF APPLICATION t
ARCHITECT PLAN CHECK FEE P.C.NO.
oR PANELS ER 200 AMP) 20.00
NGINEER
Ss�.uc.NoL �g3 SIGNS TRANS. 3.00
nooa'Ess ENG' /' 1 SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
2T0 W L[f zIP SO) EMP. METER P ORS. 20.00
XPPL sTa MOTORS E FEE SCH.
O SO y7 (� SERVIC ANGE 20,00 Iy 2 91990
o 0 i
r o o LICENSED CONTRACIURS UCLA RATION . .
a is U 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
z w Icmnmm�cing with Section 7000)of Division 3 of the Bu,iness and
PLG. MECH.
H �- Professions Code.�Il my license is Nn full for / -
0 o'u2 - License Class �O ConNumber
' 9ZH °w Uatc/D - Comm
F H _ �
T w a OWNER-BUILDER EC ARA ION BUILDING PERMIT
a o'c " MISC.— REFER TO ORD INFORMATION
FLLojF I hereby allirm (hal I am exempt front the Contractor's License VALUATION
Law for the following reason, 7031.5.Businessand Professions PERMIT ISSUANCE 1g,Op So/FT.
3 Code:Any city or county which myuiresa l'rrmit o it, nine ,aha -/v �
2 Ir ¢ O impmvc,demolish,it repair any sUudure,prior to it,issuance,also' ELEC.CONTR. LIC.NO. ELEO
O u require the applicant for such permit to Ek a signed statement that TOTAL
PERMIT TO
n w he is licensed!)(commencing
the provisions o1' 00 Contractor's 3 Licans,the -
- Hzi Law(Chuprcr')(commcncingwith Section 7000)uf0ivisiun3of the
z o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
re I- $ the basis for the alleged exemption.Any violation of Scclion 7031.5 STORIES TYPE CONSTR.
n , by any applicant fora pennit subjects 5500),licmtt toacivil penahy TER-DRAIN&VENT-WATER IEA.1 .00
of not more than five hundred dollars fS500).):
❑ L.as owner of the property,or my employees with wages as gq FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Profe"bon, DRAIN LOOK,ROOF,AREA,CO D. 5.00 PX
Code:The Contractor's License Law does not apply to an owner of 09
property who builds or improves thereon,and who dors such work FIXTURES ER TRAP 5.00 RD.FT FLOOH AREA TOTAL ACREAGE
himself or through his own employ mss,provided that such intpruvu-
mentsarenolintendedorofferedforsale.If,however,the building GAS-EA.SV$ M-I INCA TLETS 6.00 g J, ?�
or improvement is sold within one year of completion, the owner- GAS-EA.SVSTE -OV 4 (EA.) 2.00 c 1 O
builder will have the burden of proving that he did not build or int- BUILDING USE
prove 1,aS opner of sale.). RESINDUSTRIAL WAST TER. 30.00 Q I❑ ❑N ® p❑
❑licensed c owner of the properly,he exclusively.7044,ing with
andP, contractor;Cod to construct the prosect La 7044,Business LAWN SPRINKLER -1 C5V.B. 6.00 ASSESSORS PARCEL No.
and Professions Code:The who
builds s License law docs not apply
to tr owner of properly who builds tr improve thereon,and who LAWN SPRIN KL S-OV E IEA.1 1.00
thermos for r', projects with a contractors)licensed pursuant m
'
the Contractor's License Law. SEWER-SANIT RY-STORM EA. f[/10.00 TRACT No. PARCEL No.
❑ lam exempt under Sec. ,B.&P.C.for miss
reason WATERHE ERW/VENT 6.00
Owner ')are WATER STEM ACC.GATE ACC.FILE NO.
WORAERS'COMPI:NSATION DECLARATION WATE TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent Wself-inure,
or a certificate of Workers Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thcrcof(Scc 3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. RE SPRINK ENERGY F Z Certsu-s•dsL��,oyy tl��II wl��LL �cityriylion Jivisiun. a O ❑
p
Applicant(' df0 CJ/JS ./���l�c' MISC.- REFER TO ORD. Y N
.XT CERTIFICA'1'1i OIs 17XEMFI]ON FROM WORK E RS' PERMIT ISSUANCE 10.00 FLOOD ZONE A. .Uc.
LU > COMPENSATION INSURANCE PILO.CONTR. LIC.No. PLG.
CL O IT his section need not be completed if the permit is for one TOTAL Y E) NE) V E] N�
0 Z IT
dollars IS 100)or less I
U O 1 certify that in the performance of the work list which this per. OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL I- not is issued.1 shall not employ any person in any manner so as to
become subject to the Workurs'Compensut ion Laws of California.
} i Dmc Applicu"I LTER OR ADD TO MECH. 500 BUILDING
W NOTICE TO APPLICANT': If,after making this Certificate of Es-
2 emption,you should become subject to the Workem'Compensation AP IANCE 5.00 PLAN CHECK
isi ' 6
provons of the labor Codc, you must forthwith co,,,ly with FEE
U such provisions or this permit shall be deemed revoked AIR LING UNIT(TO 10 C.F.N.) 4.00
CONS'FROM ION LENDING AGENCY AIR HANDL UNIT(O 10=C.F.M.) 6.00 SEISMIC FEE SO
I hereby affirm that there is a construction lending agency for EXHAUST HO ( H DUCT) 5.00 L
the perfornance of the work for which this permit is rested(Sec. MICROFILM
3097,Civ.C.). � Q ,p,. / HEATING UNI 100,000 B.T.U.) 8.00
Lender's Ntm ee_! " o
Lenders Address - .�_���� HEATINGU T(OVE 0,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this apphcali nt and state that the Ibuve V ENTI L ION FAN (SIN 1 4.00
information is state
I spree to comply with all city cti county PLUMBING
ordinances and state laws relating to building construction,stydco and BOI COMP(3 H.P.or 100,00 T.U.) 6.00
Itennhereby authmiec representatives of this city to enter upon the BOI VR-COMP(Owr 100,000 BTU)SENE SCH. MECHANICAL
ul u ro property for inspect this
ion purposes.
(We) agree to save, Indemnify and keep harmless the City'of MISC.- _ REFER TO D.
Cupertino a inst liabilities,ju IcnD. Sts and expenses which PERMIT ISSUANCE Tp,gO CONST.TAX
ay ' way ecru ga' aid y in ronselpici c of the
his tit. - MECH.CONT. LIG NO, MECH.
-ZD�a TOTAL TOTAL
i fire ofA plic ontrecmr Dam /
OFFICE COPY
- I