6569 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
/
BUILDING APPLICATION & PERMIT 6569
aDDRE55 /7
BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S -- PLAN CHECK VALIDATION
N T lEE /^l/ QTY. ELECTRIC PERMIT FEE
U PHONE
NA.ERacroRs UTLETS-SWITCHES-RECEP 5.00/1.00
I'Xlb LVn /A UCNO. LIGHTING FIXTURES 5.00/1.00 -
DRESS
A APPLIANCES-RESIDENTIAL 4.00 -
C, TRA5
O&OOJ V _e PHONE 7dG O PANELS 5.00 DATE OF APPLICATION
IECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENc' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS . SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
w o o LICENSED CONTRACTORS DECLARATION
a 1 heminy affron that I am licensed antler provisions of Chapter 9 r ISSUANCE DATE
i,C n (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r w z I'rol'es`i1'1ts Cndv lyy license is ill lull f<'D;,�lyl y,[f� ❑ ❑ 1:1
❑
Z
o w- Liccnx lass C. L+--Lic.Nun en=/DSY „
Contracto )I
Ix w OWNER-It UILDIiR DEC' RATION BUILDING PERMIT
X ;LL m 1 hereby ufftrm that I am exempt from the Contractor's License MISC.- REFER TO ORD INFORMATION
H .. o j Law for the following reason:(See.703 L5,Business and Professions PERMIT ISSUANCE VALUATION $/FT.
Code:Any city or county which requiresa permit loconstruct,alter, 6.00
IS Q¢ improve,demolish,Or repair any Structure,prior to Its Issuance,also ELEC.CONTR. LIC.NO. ELEC.
ILLO u requires the applicant for such permit to Glc a signed statement that - TOTAL PERMIT TO
u w m y he is licensed Pursuant to the provisions of the Contractor's License
H z a
Law(Charnel 9(commencing with Suction 7000)of Division 3 of the �LGJ/yBiN 1I
i o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
LIE I- o the basis for the alleged exemption.Any violation of$ection 7031.$ILL STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil Penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
ofnot more than live hundred dollars($500).): ci
.❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00
their sole compensation,will do the work,and the structure is not oce.Group RES:UNITS-
intended or offered for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractors License Law does not apply to an owner of
property who builds or improves themun,and who does such work F IXTUR ES-PER TRAP 4.00 so.Fr.FLooR aREa TOTALACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered lot sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
nr improvement is sold within one year of completion.the owner-
builder will have the burden of proving that he did not build or inn- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
prove for purpose of sale.). - INDUSTRIAL WASTE.INTER. 20.00 RES IND CON PB Omer
❑ 1,as owner of lite properly,am excursively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 11NC5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor'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 contractorts)licensed pursuant to
the Contractor's license Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sea ,B.&P.C.for this WATER HEATER p7 fiM
maom 4.00
Owner Date WATER SYSTEM 4.00 ACC.OATE ACC.FILE NO.
WORKERS'C.OMPF.NSA'fION DECLARATION WATER TRE 59-Y11884 4.00
1 hereby aIll,. that I have a cerlifcate of consent to sel4insure.
6r a certificate of Workers Compensation Insurance,Or u certified t ZONING ENG.SITE NO.
copy thereof(Sec 3800,Lab.C:(J u/ kr 1hMiC It el U ertino
Policy No. ComP:mY_{`-0�"4 �U✓_�>;
Q ❑ CcrlilicJ 'opy is hereby lurmslcd. FIRE SPRINK ENERGY T-24
z- Oil
Cc icJ opy d witl the city inspeul ion Division.
FO APplicant�Lr>_+-,_�� MISC. REFER TO ORD, v ❑ N❑ v ❑^ ry❑
CC N CI: 11 ICA'FE OF IiX:A1PTION FROM WORKERS' PERMIT ISSUANCE 6.00 �p FLOOD ZONE AT.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This section need not he completed if the permit is for one TOTAL l)O V❑ N❑ V❑ ry❑
Z hundred delta,,1$100)or less.)
U O 1 certify that in the performance of the work for which this per- TY. MECHANICAL PERMIT FEE FEE SUMMARY
U_ I- nlit is issued,1 shall not employ any person in any manner so as to
Ow become subject to the Worker.'Compensation Laws of California.
n Lite Applicant ALTER OR ADD TO MECH. 4,00 BUILDING
} So NOTICE TO APPLICANT: If,after making this Certificate of Ex-
? emption,you should become subject to the Workeri Compensation 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.NL) 3.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm Her 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.Civ C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name _
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
1 certlly that I have read this application and stat,that the above VENTILATION FAN (SINGLE) 3.00
inner....tiom is correct. I agree to comply with all city and county
c ordinances and state lows relating to building construction. and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4PLUMBING.
00 l
hereby aulhoriZerepresentatives of this city to enter upon the
ahove-mentioned property for inspection purposes. BOILER-COMP (Over 1OQ000 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 PERMIT ISSUANCE CONST.TAX
in any way accrre against sad City in consequence of the 3.00
gr I ing of this permit' _ MECH.CONT. LIG NO. MECH.
t./1 TOTAL TOTAL
Si lure of Applicanti lfor Date
OFFICE COPY