6245 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT;DENTAIFTI&O PERMIT NUMBER
BUILDING BU APPLICATION & PERMIT
AooREssi -BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 6245
awNE SSv PLAN CHECK VALIDATION
"AME - CITY. ELECTRIC PERMIT FEEprt�p�]1/ HONE Pt'Ll�
NA CONTRACTOR's /Q UTLETS-SWITCHES-PECED 5.00/1,00
"AME
+ / - ,?,P/ ;j LIGHTING FIXTURES 5.00/1.00 9,� CCT 151984
uc.no,
r,OrvrR Gros'S f PPLIANCES-RESIDENTIAL 4.00
ADDRESS
rib,, n1 f•r.. N
PRONE � � PANELS 5.00 PATE OF APPLICATISN'OO
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.N0.
OR
ENGINEER
LIC.NO SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
P EMP.METER OR POLE INS. 15.00 f
APvuc r MOTORS SEE FEE SCH.
ADR 1
SERVICE CHANGE P 10.00
IF o LICENSED CONTRACTORS DECLARATION v
G v U1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
to< n (commencing with Section 7000)of Division 3 of the Business and Ba ELE T. PL EC .
O i Professions Code,a my license is in full fore• e
z o=- License Cl"�as5,�� a;�Lie.Number_
o Date-.Cl/^/ �Contmctur IQQ
, -5,f 2dy Qf Cppe BUILDING, ERMIT
Q ¢w ¢ OWNII R-B UILUER DECLARATION INFORMATION -
" MISC.- REFER TO ORD
C, y 1 hereby ul tiro that I am exempt Irma the Contractor's License
u o J Law for the following reason.(Sec.7031.5,Rusinessand Professions PERMIT ISSUANCE VALUATION $/FT.
E - Code:Any city or county whish reyuimsa permit to construct,alteq 6.00 Z4qrs
et 0 re improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. KUI/JI
m OF requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
X 2" he is licensed pursuant to the previsions of the Contractor's License
HiQ
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
4 O Business and Professions Code)or that he is exempt therefrom and CITY, PLUMBING PERMIT FEE
R o the basis for ilia alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
u 3'? by any applicant for a permit subjects the applicant too Civil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
of nut marc than five hundred dollars(55001.1:
13 1,as owner of fire property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP NES.UNITS
their sole compensation,will do the work.and fire structure is not
intended or offered I'..sale (See 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 does such workFIXTURES-PER TRAP 4.00 sa. r.v�oggREA TOEALACREAGE
himself or through his own employees,provided that such improve- oovv
ments are not intended or offered for sale.If,however.the budding 44 GAS-EA.SYSTEM-1INC.4 OUTLETS 4,00
or improvement is sold within one year of completion,the owner. I
GAS-EA.SYSTEM-OVER 4 IEA.1 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
prove for purpose of sale,). JINDUSTRIAL WASTE INTER. 20.00 E IND CON PB Omer
❑ 1,as owner of the property'lun exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESBORS 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 ach projects with a centractor(sl licensed pursuant to
tire Contractors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
' .
❑ Iamexempt un der Sec. .B.&P,C,oRIhis WATER HEATER W/VENT 4.00
0 soft
Omer Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK 1iRS'C0M PENSAT'ION DECLARATION WATER TREATING UIP. 4.00
I hereby alfirn that I hove a certificate of consent to sell-insure. ZONING ENG.SITE NO.
or a Certificate of Workers'ComnrsW ion Insurance or�certil'i d
copy thereof
p
'fStt,3800,Lab.C� fes/ OA
policy No.rt Company
O ❑- Certifier copy is hereby furnis a FIRE SPRINK ENERGY T 24
z Z ❑ Certie- is r. Oh t inspection do MISC.- FER TO ORD. y ❑ N❑ y❑ N❑
Applicant
O PERMIT ISSFrtt,y I 6,00 FLOOD ZONE A.L.U.C.
it - CER'FIFICA'1'1:01'EXEMPI-ION FROM WORKERS Gla
LU > COh11'E;NSATION INSURANCE PLG.CONTR. LIC.NO. PLG. /
CL O ('1'Itis section,need out be conrpleod if the permit Is for of TOTAL Y❑ N❑ Y ❑ N❑
Z himdmd Collins IS 100)Or less.) C
U O I certify that in the perfornance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued.I shall not employ'any person in any manner so as to
Ow become subject to the Workers'Compensation Laws of California. BUILDING
Date Applicant ALTER OR ADD TO MECH. 4.00
} y NOTICE.TO APPLICANT: IL after making this Certificate of Ex-
Z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Lahor Code, you must forthwith comply with FEE .�
U such provisions of this Permit shall be deemed revoked. AIR HANDLING UNIT(TO 10EEC C.F.M.) 3.00
CONS'IRI1C'I'ION LIiNU1NC AGENCYAIR HANDLING UNIT(OVER 10,000C.F.M.) 5.00 / SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of Ore work lin which this permit is issued(Sea HEATING UNIT(T0 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ.C.).
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.17.50 ELECTRIC
Lender's Address
1 certify that I have read this application and state that the above VENTILATION FAN. IN - 1 3.00
information is correct.1 agree to comply with all city and County PLUMBING
ordinances and slate laws relating to building construction, and BOILER-COMP(3 H.P.Or'10 ,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (RTO 1 0. 01 T I'S E/FEE C.H.SMECHANICAL
above-mentioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of MISC.- RE ER TO OR
Cupertino against liabilities, is a expenses which PER ISSUANCE 3.00 CONST.TAX
may in any way a � Inst City i nseyuence of the D t
t gra o - 11 MECH.CONT. MECH.
I r rr
L " /D TOTAL TOTAL J�
ign tureof Applicant Contractor Dye
OFFICECOPY a