0249 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
-16 qq
' .7 lis BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 0249
PDD
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
rvEm _ PLAN CHECK VALIDATION
NAME ly �� QTY. ELECTRIC PERMIT FEE
• Gl ONE
NONTRA ORs �1 OUTLETS-SWITCHES-RECEP 5.00/1.00
C N ALr2- LIC.NO, V3(1'71 LIGHTING FIXTURES 5.0011.00 v
CNTRAC
ADDRESS oR's y APPLIANCES-RESIDENTIAL 4.00
Q �b Ls Gn Uti PHONE f4osl PANELS 5.06 DATE OF APPLICATION
ARC TECT SIGNS 6.66 PLAN CHECK FEE P.C,NO.
OR
ENGINEER
LIC.No. SIGNS S 3.00
ARCH,OR ENG. SPECIAL 5-00 PERMIT VALIDATIONADDRESS -
ZIP EMP.ME OI LE INS. ±CH. / /y`
APPucnrvrs MOTORS y SEE FEE SCH. �J-
AooREss
GSERVICE CHA 10.00
w o o LICENSED CONTRACTORS DECLARATION
a u u 1 hereby affirm that 1 am licensed under provisions of Chaliter 9 ISSUANCE DATE
Haw (commencing with Section 7000)of Division 3 of the Business and _ LOG ELECT. PLG. MECH.
H H z Professions Code, qd my license is in full fore n �c ❑ ❑ ❑
z O m - License ss J Lie.Number
9 z au Uate _ Contractor
`a Y s BUILDING PERMIT
BE BE w 4 OWNER-BUILDER DECLARATION INFORMATION
A odU MISC.- REFER TOORD
wS LL H I hereby affirm that I am exempt from the Cool.actors License
u• oa Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE VALUATION $/FT.
Code:Any city or county which requires permit to construct,alter,BE 6.00 / ry oQ v
BE G 0 improve,demolish,Or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. / 00 /
-O u requires the applicant for such permit to tale a signed statement that TOTAL PERMIT TO
wm he is licensed pursuant to the provisions of the Contractor's License
Fii Law(Chaplxr9(commencing with Section 7000)ofDivision 3 of the /N-T(, (ORS 0�(r
- 4 Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE /y
BE r $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
03 _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
of not more than five hundred dollars(S500).):
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 2.00 DEC.GROUP RES.UNITS
their sole compensation,will do the work,and the 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 Law does not apply to an owner of
property who builds or improves thereon,and who does Such work FIXTURES-PER TRAP 4.00 So.FT.FLooR AREA TOTAL ACREAGE
himselfor through his own employees,provided that such improve-
: mems are not intended or offered for sale.If.however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or insprovement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or int- RES IND CON PB Omer
prove for purpose of OIL.). INDUSTRIAL WASTE INTER. 20.00 El 11 11 ❑ F-1❑ I,as owner of the property,am 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 Contractors 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 is eontractods)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.]or this WATER HEATER W/VENT 4.00
rec,00
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC,FILE NO.
WORKERS'CONPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby a hInl that 1 have a certificate of consent to sdtGinsure. ZONING or a"rtificale of Workers'Compensation Insurance,or B certifiedENG.SITE NO.
copy thereof(See.3800,Lab.C.I�" " rU '
Policy No. Colnpany`,z4.T7r_ u
Q ❑ Ccrlilsed py is hereb ornlsl FIRE SPRINK ENERGY T 24
_z Z 'B�Certifie, py e Lei y I Aivisio°' MISC.- REFER TO ORD.
O Applicant v ❑ N❑ v [-] NE]
Fru PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.uc.
LU > CIi R'I'IPICCOEVE SAfION ION PRO URR ERS'
LU _ COMInot beT ora INSURANCE PLG.CONTR. LIC.No. PLG. Y❑ N[_ Y ❑ N❑
C O (This section need not be completed if the permit is for one TOTAL
D Z hundred dollar,(SI00)or less.)
U O 1 certify that in IIIc pL't ra m¢u of Ise wU, Ir w i- 's p•- TV. MECHANICAL PERMIT FEE FEE SUMMARY
ly H mit is issued,1 shall not employ a pe ny
O IV becolyvsupy�c�.tu tI Workeri C La
a
DateJC/_S-d'L Applican u ALTER OR ADD TO MECH. 4.00 BUILDING �..t �,fo
} W
NO] CE you
APPLICANT: IL ilea cookie .his r,'C.m,L t -
FZ provisions of shouldbecomeCode,
rouse Wrthwit'Compensation APPLIANCE 4.00 PLAN CHECK
provisions io the Labor Code, you must drevoke congrly with FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10,000 C.F.M.) 3.00 1
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10)000QF.M.) 5.00 SEISMIC FEE �� .2 ,61
1 hereby affirm that there is a constrfetion lending agency for EXHAUST HOOD (WITH DUCT) 2.00
rise pe,m m:mcc of.he work Ibr which this permit is issued(Sec MICROFILM
3097-Civ.C.)L HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.17.50 ELECTRIC
Lender's Address /
I Lushly that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
.irdornistion is correct. I agree to comply with ail city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
• adi farces and stale laws relating m building construc.io4 and
,bereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
abuvamcmiuned property for inspection purposes. -
(We) agree to save, indemnify and keep harmless .he City of MISC.- REFER TO ORD.
Cupertino against liabilif ,judgm is Bost and expenses which CONST.TAX
may in an way ce ugai t n co •comes, of the PERMIT ISSUANCE 3.00
granting .hi' a MECH.CONT. LIC.NO. MECH,
TOTAL TOTAL � r7�
'^'� ignanne ol'AppliwnljContractrn Uum
OFFICECOPY '