C 6108 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
APPLICATION & PERMIT
BUILDING
2M
s
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 6108
OWNER'$ /V - PLA CHECK VALIDATION
rvaME G OTY. ELECTRIC PERMIT FEE
vHary
EaAcioas
N OUTLETS-SWITCHES-RECEP 5.00/1.00
S+c(/JCGyTc.No. ZI
1 LIGHTING FIXTURES 5.00/1.00
CONTRACTOR
ADDRESS /A1124_ *C& APPLIANCES-RESIDENTIAL 4.00
m/� O
3 PH.-Cf40-aigoo PANELS 5.00 DATE OFAPPUCATION
ARRCHITECT SIGNS 6.00PLAN CHECK FEE P.C.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00 P ID
ARCH OR ENL. SPECIALCIRCUIT -5.00 PERMIT VALIDATION
ADDRESSZIP TEMP.METER OR POLE INS. 15.00 (JUN 2 71965
AvvucANrs Op7/� W
ADDRESS O 7 t,- MOTORS SEE FEE SCH.
D
SERVICE CHANGE 10.00 CRY Of CUp ertino
o¢ i
F 0 o LICENSED CONTRACTORS DECLARATION - 'WAts Q
a v I hereby affirm that I am licensed under provisions of Chapter 9 y-� �L :r.p (/ ISSUANCE DATE
N2w
(commencing with Section 7000)of Division 3 of the Business and B DG. ELECT. PLG. MECH.
F w i J'rofessi'Ro Cod• r ease is in full fort- ❑ ❑ ❑
z 0 m -- Licenu[llyy� �Lic.Number
om�-w Dulc-(6 Contruamb '
¢ a w a OWNER-BUILDER DECLARATION
BUILDING PERMIT '
mo a" INFORMATION
;LL r I hereby affirm that 1 am exempt from Om Contractor's License - MISC.- REFER TO ORD
IL O j Law for the I'ullowin rwson.(Sec.7031.5,Busmessaad Professions a 6.00 vgWAT10� $/FT.
- g PERMIT ISSUANCE
E "'0 Cade:Any cityorcounly which mquirna permit to construct,alter, 10.
Ce¢ ¢o improve,demolish,or repairany structure,prior to its issuance.also ELEC.CONTR. LIC N0. ELEC., �/
ar
O M requires the applicant for such permit to file a signed statement that TOTAL
a w m he is licensed pursuant to the provisions of the Contractor's License - PERMIT TO
Fi>
Law(Chapter 9(Commentingwith Section 7000)of Division 3 ofthe '
4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE /[46__ r
Se I-m the basis for the alleged exemption.Any violation ofSection 7031.5 STORIES TYPE CONSTR.
n ; _ by any applicant for a permit subjects the applicant to a civil Penalty /
of not mom than five hundred dollars(S500).): ALTER-DRAIN III VENT-WATER IEA.) 4.00
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECTDEV ICE 2.00
their sole compensation,will do the work,and the structure is not . OCC.GROUP RES.UNITS
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work F IXTUR ES-PER TRAP 4.00
1 - SO.FT.FLOOR AREA TOTAL ACREAGE
himself re riot
intended
his own employees,provided thin such ire building
I mm�tsarCnot intended or within
one
sale.I If, the huilding GAS-EA.SYSTEM-1INC.4OUTLETS 4.00 �!� G .O
v iderrwill have
t is e b within one year of lie did
Dm owner- GAS-EA.SYSTEM-OVER 4(EA',) , 1,00 e
builder will have 0u.'burden of caving that he did nut build or ire- BUILDING USE
prove 1,as npose of sale.). - INDUSTRIAL WASTE INTER. 20.00 R IND CDN PB Other
❑ d as owner of the property,amexclusivelyproject
Se contracting wish � ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs not apply
toan trowner W'progenywho buildsor trimpmacs Utsedpuand who LAWN SPRINKLERS-OVER 5(EA.)' 7.00
contracts for such projects with a contractor(s)licensed pursuant to
pm Consmctar's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam Cicmpt under Sea ,B.&P.C.far this WATER HEATER W/VENT
w n 4,00
Owner
Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE N0.
WORK FRS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby alfirm irm that I have a certificate of consent to self-insure.
or u Certificate
Iaatte`Io_tff W}Aamerrrs'Com�p�erssat�ion Insurance,
/or a�cerwtified ZONING ENG.SITE NO.
Yrs LM1vwR �Y JIr ;Y JALC� 'r/e/V UI// s
�- - Cer IicJ cu chyy furor bed. FIRE SPRINK ENERGVD
Z Z &JYCerldic TU wrt the city it spccfon division. 24
F p npplicum_ � 1- MISC.- REFER TO ORD. ' Y 0 N❑ v Q N[3
CCN CFRI'IFICA'TIi OF EXEMPT'10 'ROM'ROM W( PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d 0 (Phis section need not be Completed if Ire permit is for one TOTAL Y N Y❑ NE]
U O hundred dollars($100)or less.) ,
I certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
EL U mit is issued,I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
y Dan Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} ED NOT 'I O APPLICANT: If,after making this Certificate of[:a- o!
F. a ippon,you should become subject to the Workeri Compensation APPLIANCE 4.00 PLAN CHECK
U such provisions or this visions of the bpermor it shall be deou emed revoked.st forthwith comply with AIR HANDLING UNIT(TO 10=CF,M) 3.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MOC.F.M.) 5.00 SEISMIC FEE
I hereby alfinn that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the perfunnancc of Ibe work for which this permit is issued(Sec. MICROFILM
3o97,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Larder's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
1 cerlily that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to Comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.01100,000 B.T.U.) 4.00
herebyauIhorlre representatives of this City to enter upon 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 Om City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
ff91Fgp.w,C
wa Cc agar st said City in consequence of the PERMIT ISSUANCE 3.00
hr er MECH.CONT. LIC.NO. MECH.
r-Dte z TOTAL TOTAL
Applicant/Conlrac ate
OFFICE COPY