2741 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE'BALL POINT PEN DNC.
BU LD1 NG PROJECT I DENTI FICATI ON rER T MBER
aD,LDING APPLICATION & PERMIT r� � /I �q
.. AOOness " (, �F I
T:�s�J lClgY BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S .� ' PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
•� a ��r�� PHONE _
NAMER, R� OUTLETS-SWITCHES.-RECEP5.00/1.00
uli.No LIGHTING FIXTURES. 5.00/1.00 - -
ADDRESsroas APPLIANCES-RESIDENTIAL 4.00
'62< PHONE Z PANELS 5.00 DATEOF APPLICATION
' oq ITECT r SIGNS 6.00 PLAN CPUT7PaC.NO.
ENGINEER
LIC No. SIGNS TRANS. . 3.00
.ARCH.OR ENG. PERMIT VALIDATION
ADDRESS SPECIALCIRCUIT 5.00
,: - '. _ - ZIP ITEMP.METER.ORLPOLE INS. 1 15.00
APPLICANT'S
� ADDRESS ' ;`: 4MOTORSSEE FEE SCH. O
-.Sm� L Lv0 0 : 95/ SERVICE CHANGE 10.00
w o o'LIC12NSED CONTRACTORS DF-CLA RATION 0
a U I herchy affirm that 1 am licensed underprovisionscf Chapter9 ISSUANCE DATE
m z w (commencing with Section 7000)of Division 3 of the.Business rad
a n BLDG. ELECT. PLG. MECH.
r N i 'Professions Code,and�my license is in full force and it'
z 0 m - •License Class-Q-3(�Lic.'Number�Q�}�7�
Dole/-- Contractor
H y/� / 3-' -
a m fry f BUILDING PERMIT
¢ a'a
OWNER-BUILDER DECLARATION '
INFORMATION
X ; y 1 hereby affirm (hat I am exempt from the Contractor's License MISC.- REFER TO ORD
LL O 4 Law for the following reason.(Sec.7031.5,Businessand Professions VALUATION $/FT.
- g PERMIT ISSUANCE - 6.00
Code:Any city or county which requiresa permit(a COnSFUCL alter,
E
at c o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
n w0 LL rt•Il Wren the applicant for,uch permit 10 file a ailment statement that TOTAL PERMIT TO
m he is licensed Pursuant to(lie provisions of the Contractor's License /'
Luw(Chapter9(commenciitgwith Section 7000)of Division 3 of the (j-�,#-s' On/�'
a Business and Professions Cadet or that he is exempt tlterolrcnn and DTV. PLUMBINGPERMITFEE
or r $ the busts for the alleged exemption.Any violation of Section 7031.$ - STORIES _ TYPE CO STR.
a 3 of not applicant fora anleddollar, $500file licant(uncivil peWaty ALTER-DRAIN -WATER (EA.) 4.00
of not,naso woe five hundred dalton Imy em: -
❑ I,as owner at Ilio property,or my employees with wages ot BACK FLOW PROTECT. DEVICE 2.00 - OCC.GROUP RES.UNITS
.
their sole compensation,will tla the work,and the structure is not ,
intended or offered for sale (See. 7044,'Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:'file Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SG.FT.FLOOR AREA TOTAL ACREAGE
himself or through his ownemployees,provided that such improve.
mints are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I1NC.4OUTLETS 4.00 '
ar'improvement is sold within one year of completion,clic owner GAS.-EA.SYSTEM-OVER 4 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- - RE5 IND CON Pe Otner
prove for PurPOse 01,Sade.). INDUSTRIAL WASTE INTER. 20.00
13I,as owner of the property,am exclusively connecting with ❑ ❑ - ❑ ❑ ❑
licensed contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS- 1 .BT 1 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of.propercy who builds or improves thereon.and who ILAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed Pllrsllan(ar
the Contractor's License Law. SEW ER-SANITARY-ST I TRACT NO. PARCEL NO.
❑ tum exempt under Sec. ,B.&P.C.fnr this WATER HEATER W/VENT 4.00
nusmt
Dole - Owner WATER SYSTEM 4.00 ACC.DATE ACC,FILE NO,
WORK I;RS'COMPENSAT ION DECLARATION WATER TREATING EQUIP. 4.00
'I herchy affirm that I have n tortificute'nf nntsatt to Sul Gins'I,m: ,�, i ZONINGS ENG.SITE NO.
- or a certifieale of Worker"'
orkers Compensation Insurance,ar n certified
copy thereof'(Sce.3800,Lah.C.).
Policy Na. � Company
Q ❑ Certified copy is hereby furnished. - FIRE SPRINK ENERGY T-24
Z ❑ Cerlified copy is filed with the city inspection division. - MISC. - -REFER TO ORD. ❑ ❑ ❑ N❑
O Applicant V N' Y
LO CER'PIFICAT'E OF EXEMPTION FROM WORKERS' ' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
W >' COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL I'I'his action need net be Completed i(Nle Permit is for one _ TOTAL Q G Y❑ IN V ❑ N❑
D Z hundred dollo,s(5100)or less.)
U Q - I certify that in the performance of the work for which(his per O V. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issucJ,I c em Ploy un ersan in any ntu nos to
O U hcconrn subjen m t ar ors m ensaRo ews a um
)ate/�=.j="�?41ppI'e ALTER OR ADD TO MECH. 4.00 BUILDING
} m NOT( Ii TO APPLICANT' aUer mast g this Cer(ificam of ix
F Z empties,you should hoc subjen m the Workers'Compensa ' I APPLIANCE 4.00 PLAN CHECK
provisions al' ilio Labor Cody, you must forthwith comply wi Bl FEE
U such provisions or this permit shall be deemed revoked.. - AIR HANDLING UNIT(TO 10=C.F.M.) 3.00 - _
CONSTRUCT ION LENDING AGENCY ' AIR HANDLING UNIT(OVER 10JMC.EM.) 5.00 SEISMIC FEE
I-hereby affirm that there,is a construction lending agetroy for EXHAUST HOOD(WITH DUCT) 2.00
Ilio per f..moncr of the work I'or which this permit is issued(See. MICROFILM
3097,Civ,C.). �- - HEATING UNIT(TO 100,000 B.T.U.) 4.00
London's Na,nc EUT(OVER 100,000 B.T.U.)7.50
Lender'sNo v.s HATINGNI
ELECTRIC
' I cert ily ([lot I have read chis application and stole chat the above VENTILATION FAN (SINGLE) 3.00 -
'inl'onnucion is correct. I agree to comply with all city and county BOILER-COMPI(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING - 0
e It dinonces and slate laws relating to building construction, unrl
Rlhy aulhori,erepresentatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
uhuv -mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against IiabP* sand expenses which CONST.TAX may in any w rue 'gains) said City i sniuence of the PERMIT ISSUANCE 3.00
granting of this permit' MECH,CONT, - LIC.NO, MECH.
TOTAL TOTAL
>1`95.11.or oilpIPtaintilLoutuict., _ Date
/ \ OFFICE COPY
L -