0517 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT P ONLY
BUILDING PROJECT IDENTIFICATION I J I
PERMIT NUMBER
BUILDING APPLICATION & PERMIT
AOOREILnINE Mr
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DUO�tl/p M( fi4�
..He.. q "m PLAN CHECK VALIDATION
TYNA( Za48L r ii
OELECTRIC PERMIT mFEE
PHONE M1 F .• - ,.1 _j
CONTRACTOR'S
NAME UTLETS-SWITCHES-RECEP 5.00/1.00
LIC.NO. LIGHTING FIXTURES 5.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS 9/16 -
vHONE PANELS S.00 DATE OF APPLICATION
ARCHITECT SIGNS Q,QQ PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
Srvrs
ZIP EMP.METER OR POLE INS. 15.00
A
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00 6 /
0 0 o � // /�j
LICENSED CONTRACTORS DECLARATION
<u u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
N a w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F 4D'R Professions Code nd y license is in full force
z o w License��Clayy Lic.Number ❑ ❑ ❑
Z L w/ Da Contractor
a ae J ���••����W E� +s4 *BUILDING;PERMIT;"
Ic c W a OWNER-BUILDER DECLARATION UI&INF•ORMATION,'
d o A ca MISC.- REFER TO ORD "`'
X ; LL N I hereby affirm that I am exempt from the Contractor's License VALUATION S/FT.,
H_ 04 Law for following reason. 7031.5.Businessand Professions PERMIT ISSUANCE 6.00
J Code:Any city or county which requires a permit to construct.alter,
2 2 < 2O improve,demolish.or repair any structure,prior to its issuance,also ELEC.CONTR. - LIC.NO. ELEC.
n F D LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
W$ m he is licensed pursuant to the provisions of the Contractor's License
I, i >
Law(Chapter 9(commencingwdh Section 7000)of Division 3 ofthe `'cl « YA ""'T "Su- '+TS'r -L,.aVI,,,rlyi♦; pr yp sy., 1 V/N'
4 c Business and Professions Codec or that he is ezempl therefrom and OTY: S d 'PLUMBING_PERMIT,J Q.s +• y FEE:'•
M I-$ the basis for the alleged exemption.Any violation of Section 7031.5 S':i.•is i.,'�-`5 !]i ' S•Myiy STORIES TYPE fDNSTR.
a ; _ by any applicant for W.hund,eddoIlaC,(he01L): am toacivil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars 155001.1:
❑ 1,as owner of the property,or my employees with wages as BACK 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 DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
properly 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- G Y TEM-11NC.40UTLETS 4,00 `
ments are not intended or offered for sale.If,however,the budding
or improvement is sold within one year of completion,the owner, GAS-EA.§ R 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Orion
prove for purpose of sale.). I - RIA WASTE INTER. 20.00
O 1,as owner of the property,am exclusively contracting with ElEl ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRI 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 RINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractorls)licensed pursuant to SEWE RY-STORM
the Contractor's License Law. EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 4,00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm (he( I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers Compensation Insurance,or a certified
Polis he NS b.Y.l. �_ u
Q It Certified copy is hereby furnishe FIRE SPRINK ENERGY T-24
Z Z ❑ Cer'led copy Is kd itis the city inspection division. MISC.• REFER TO ORD.
O APPlicant Y C] NE] Y C] No
ECwCERTIFIC OF EXEMPTION M WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
PENSATION INS U ANCE PLG.CONTR. LIC.NO. PLG
W C ,
d 0 (This section need not be completed if the permit is for one TOTAL V ED, N❑ Y❑ N❑
U Z hundred dollare($100)or less.) s:'rft 's "+• }'I if, "t'_ ., I Y.� �
U O I certify that in the performance of the work for which this per OTV 1` MECHANICAL PERMIT,r 4t'a e 7 FEE -I �fFEE'SUMMARY.)
LL mit is issued.I shall not employ any person in any manner so as to . .a,• •--, r 4tzs- K k
become subject to the Workers Compensation Laws of Califomla.
0 Date-Applicant BUILDING
aALTER OR ADD TO MECH. 4.00
} m NOTICE TO APPLICANT: If,afar making this Certificate Compensation
Ez-
? eruption,you should became subject to the Workers'Ccomply wit APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT ITO 10MEIC.F.M) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 1040DICRIA) 5.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agent' for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). ��� HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that I have read this application and slate that the above VENTILATION FAN(SINGLE) 3.00
information is correct.1 agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
• ordinances and slate laws relating to building construction. and
"linreby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000BTUI 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 CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00 fW;
gra ling of this perrint4 MECH.CONT. LIC.NO. MECH, rf p'+el;iCJ;rt k,"Zs�7
e TOTAL 1�,- P,TOTAL=�'axy`f 7•49
Signature.1A Imam/Contract Dal •'•f-:- �".'i 4._T Ml4!
OFFICE COPY