4628 APPILICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI- POINT PEN ONLY
BUILDING PROJECT I DENTIFI CATION PERMITNUMBER
EDILDING APPLICATION & PERMIT /� 0
ADOEESS BUILDING -ELECTRICAL-PLUMBING -MECHANICAL Y O
,2o4vo
OWNER'S % PLAN CHECK VALIDATION
"AME O ELECTRIC PERMIT FEE
h uA 6mPA PRONE -
CONTRACTOR TLETS-SWITCHES-RECEP 5.00/1.00
kAME
I-, _ _ LO.No. t LIG TING FIXTURES 5.00/1.00
ADDRESs crov's gip, C�,p(Ga APPU CES RESIDENTIAL 4.00
ADDRESS
e %ZONE PANELS 5.00 DATE OF APPLICATION
x ,�
AR 'I.L SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
' uc.NO, SIGNS TRANS. 3.00
ARCH.OR END SPECIAL CIRCO 5.00 PERMIT VALIDATION
ADDRESS
cIP TEMP.METER OR P LE INS. 15.00
APPLICANT (/*oto MOTORS
ASEE FEE SCH. J
PPLICA
SERVICE CHANGE 10.00
D a i C j
r o o LICENSED CONTRACTORS I3ECL\RATION
Fzo Ironur¢emn ng lwi hthat I one Section ]OOOIsomlf Dlasi underprovisions
of mfhe Buvnesstnnl r 9 ISSUANCE DATE
H H 2 Professions Code,and my ee...v is in full force and effect. BLDG. ELECT. PLG. MECH.
z O m License Class Lo.Number ' ❑ ❑ ❑ ❑
E z D Date so
< x o• BUILDING PERMIT
w O NIiR-BUILDIiR DECLA A'f10N INFORMATION
w 3 LL I- 1 herch tfnn that I am exem t from the Contractor's License MISC.- REFER TO OR
y a p VALUATION
L Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00
- Code:Any city or county which rnluircs3 pe nmif tocolsstrua,alter,
K ¢4 0 improve,demo lisp,or re pair y suure.prior to its issuance,also ELEC.
:mtrctCONTE. LIC.NO. ELEC.
0 LL re "ares the Jpp11Ca0[(Or Such PeRnit to file a signed statement that TOTAL PERMIT T
d m he is licensed pursuant to the provisions ofthe Contractor's License �(�f
UP Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
- < Business vW Professions Code)or that he is Pvempt therefrom and QTY. PLUMBING PERMIT FEE
r Oo the basis for the alleged exemption.Any'violatian of Section 7031.$ STORIES TYPE CONSTR.
A.
by any applicant for a permit subjects the applicant to a civil penalty TER DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars($500).):
❑ h as owner of the property,or my employees with wages as BA FLOW PROTECT. DEVICE 2.00 OCC.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 DRAIN -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 FIXTURE -PER TRAP 4.00 so.ET FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not imendedoraHoned for sale.If.however.the building GAS-EA.SY EM-I INC.4 OUTLETS 4.00
or improver cut Is sold within one year of completion,the owner. GAS-EA.SVST OVER 4 (EA.) 1.00 BUILDING USE
builtler will have flit burden oC Proving that he diA not build or ire- RES IND CON PB Ore,
Prove for purpose of sale.). INDUSTRIAL WAS INTER. 20.00
❑ L as owner.lythe property,am exclusively contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- NC 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 contmctorts)licensed puremat to
the Contractors License Law. SEWER-SANITARY-STORM A.200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 arm exempt under Sec, ,B.&P.C.for this WATER HEATER W/VENT 4.00
¢asap
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE No.
W'ORKERS'COMPI'.NSATION DECLARATION WATER TREATING EQUIP. .00
I hereby'affirm that I have a cvn fmate ofamsent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance.or a certifieJ
copy thcreol(See.3800.Lab.C.Lina`• f
Policy No. Company�Y iN4. a i.IP45Ati
Q ❑ Ccrtlfied copy is hereby fundcll of 1 FtRESPRINK ENERGY T-24
Z_ 2 't4 Certified copy is tiled with chv iR& ... Vision. M,SC. REFER TO ORD. Y [:] IN Y ❑ IN
Applicant 1, V
F- go#J ,w'•05/r/a ILALn(W- -V PERMIT ISSUANCE 6.00 FLOOD ZONE A.LU.C.
CER r1l'IG1'irE OP l:. fiM1 PION FROM WORK.RS'
LU >' COMPENSATION INSURANCE PLG.CONTE. LIG NO. PLG. Y❑ N❑ V ❑ N❑
C Tfl, section need not be completed if the permit is I'or one TOTAL
2 hundred dollars 151001 or loss.)
U O 1 certify that in the perlormmnce of the work for which this per- GTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL P mit is issued, I shall not enmploy any person in any mminerso as to r
OL) become subject to the Workers Compensation Laws of California. ,� r,xA BUILDING
y Dato Applicant ALTER OR ADD 4&1 4.00
} rn NOTICE'f0 APPLICANT: If,after making this Certificate of Ex-
FZ emptier,you should beemnesubject to the Workers'Compensetion APPLIANCE 4.00 PLAN CHECK
provisions of the tabor Code, you must forthwith comply with FEE
U such provisions or this permit s]m11 be deemed revoked. AIR HANDLING UNIT 4 3.00 .UG
CONSTRUCTION LENDING AGENCY I AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 0'It SEISMIC FEE
I hereby affirm that there is a construction leading agency]or 3 EXHAUST HOOD(WITH DUCT) 2.00 ,00
the performance of the work for which this permit is ism ed(Sec MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that I have read this application and state that file above VENTILATION FAN (SINGLE) 3.00 g�00
inlormut ion is correct. 1 agree to comply with all city and county / •y PLUMBING
ru
ordinances and .state laws totaling to building constction, and BOILER-COMP( . . .'b /
hereby authonic representatives of this city to enter upon the , BOILER-COMP love,100,000 BTU)SEE F EE SGH. 24,'• MECHANICAL W �-
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 CONST.TAX
may 'n way ac re ae 'mst said City in const aorto of the PERMIT ISSUANCE 3.00 'a •DD
gr t g ,Itis c mi. MECH.CONT. LIC.NO, MECH. 15
TOTAL er✓/•1✓15 TOTAL
` `` int.
Si na[uru o(APPIic nl Conlmc4v etc (�
OFFICE COPY