2992 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI_ POINT PEN ONLY
BUILDING PROJECT I DENTIF I CATI ON ER aER
BUILDING APPLICATION & PERMIT (�(�
aDURES$ /� p l 9\1
o (o3q A 1f_LJoO� 1cL� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
AME OTY. ELECTRIC PERMIT FEE
ro Er 'cF PHDNE $5'1333
CONTRA ORs OUTLETS-SWITCHES-RECEP 5.00/1.00
NAME n
EI (J\ POo'F."I Ib ZNC - G ND. 2 8q3 Zi3 LIGHTINGFIXTURES 5.00/1.00
CONTRACTORS I APPLIANCES-RESIDENTIAL 4.00
A RE$$ p
40 (_t N IIG VF PHONE Z 8�1� PANELS 5.00 DATE OF APPLICATION
F
ARCHITECT SIGNS - 6.00 PLAN CHECK FEE PIN0.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.ORENG, SPECIAL CIRCUIT 5-00 PERMIT VALIDATION
ADDRESS
ZIP FFEMP.METER OR POLE INS. 15.00 9-46
� n
ADDRESS T's MOTORS SEE FEE SCH. (`///�-46
aoOREss
SERVICE CHANGE 10.00
02 LICENSED CONTRACTORS DIiCLAkA'fIOK O -
a it I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
w G H (commencing with Section 7000).of Division 3 of the Business and BLDG. ELECT, PLG. MECH.
F w ¢ Professions Code,and y lice sr in lull Ibrec anA •Ilett.
PAID
z; o m License Class C"?Ij Lic.Number 7 89 x 2`2 ❑ ❑ ❑
2 yr Date_./_/vy/rte: Contractor_�(F_IASyQ ��g�
BUILDING PERMIT
w OWNIi R-BUILDIiR DECLARATION INFORMATION
w g LL I- I hereby affirm that 1 am exam,, from the Com.elm's License S/FT.
MISC.- REFER TO ORD
a_o`� Law for the following reason.(Sec.7031.5,liusinexs:md Pro l'cssions PERMIT ISSUoff VALUATION
� - Code:Any city or county which reyuiresa permit to construct.alter, 6.00
R¢ FO improve,demolish,or repair any structure,prior to its issuance.also ELEC.CONTR.
O n: requires the applicant for such permit to file a signed stWcmmut tha, TOTAL pf�pyy.TO
A wIn a. he is licensed pursuant to the provisions of The Contractor's License
F z a Law(Chapter 9(commencingwith Section 7000)of-Division 3 of,he
E o Business and Professions Code)or that he is exempt therefronn and QTY. PLUMBING PERMIT FEE
th
n-o e basis for the alleged exemption.Any violation ol'Section 7031.5 STORIES TYPE C NST
Luim by any applicant for a permit subjects the applicant toacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of no,more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.Group RES.UNITS Yale compensation,will do the work,and,he structure is not
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code.The Contractor's License Low does nol apply man owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,Provided that such improve
hients mself a throuot gh
his onnemplo for hes,pen Lhowhatsuhe building GAS-EA.SYSTEM-1INC.4OUTLETS 4,00
or improvement is sold within one year of completion, the owner- GAS-EASYSTEM-OVER 4(EA ) 100 BUILDING USE
builder will have the burden of proving that h . . .
e did not build or int- RES IND CON PB Omer
prove for purpose of sale). INDUSTRIAL WASTE INTER. 20-00 ❑ ❑ ❑ ❑ ❑
O I,as owner of the property,on exclusively contracting with
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 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 contractorls)licensed pursuant to
me Contranor's Licmh,ce Luw SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO. PARCEL No.
❑ lam exempt t/der Sed _,B.&P.C.lot this WATER HEATER W/VENT 4.00
Reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKEBS'COMP.NSATIoN DECLARATION WATER TREATING EOUtP. 4.00
1 hereby affirm that I have a ecoilicat,of consent to self-insure. ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
co,y thereof(Sec.3800,Lab.C.). [aSE�df/
Policy No.6QS"I Company
Q ❑ Certified copy is hereby l crushed. FIRE SPRINK ENERGY T-24
Z Z q Certified ropy is bled with the city inspection Division. MISC.- REFER TO ORD.
O Applicant .(�/=.'h- iQnn Rei r+_��rp__;r.v G Y ❑ N❑ Y ❑ N❑
CC CIiRT'11'ICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 PLOOO ZONE A.L.0 c.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d O (This section need net be completed it' the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
D Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for whidl this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall nut clog
I anY ,ersot'in any marcher so as to
O w become subject to the Work s' sa' n Z7 California. BUILDING
0. Date Applic, ALTER OR ADD TO MECH. 4.00
} 0 NOTICE TO APPLICANT: II', ' ern in this Certificate of Ex-
F, 2 emption.you should become subject, the W'orkend Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or This permit shall be detained revoked AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION Ll'NDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the or' for h hien this permit is issued ISec HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
1097.Civ.C.L
Lender's Nano HEATING UNIT(OVER 100,000B.T.U.)7.50 ELECTRIC
Lender's Address
I certify tom I have read th' appllcatlon and state that the above VENTILATION FAN (SINGLE) 3.00
. inl'orination Is correct I ogres to comply with all city unJ countyPLUMBING
T,
ordinances and state laws relating to building constnm,Ioo, and BOILER-COMPQ H.P.or 100,000 B. U,) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(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 '3.00 CONST.TAX
may in any way accrue against said City in consequence of the
granting of this lot. MECH.CONT. LIC.NO. MECH.
TOTAL 91113 TOTAL
Sig a ore ol'Applicant/Contractor 41ite
OFFICE COPY