7149 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT _I- JNLY
BUILDING PROJECT'I DENTI FICATION PERMIT NUMBER
APPLICATION & PERMIT
ADDRESS
BUILDING
U�I,SLD'_rI.rN„'lGYf'-fiTf•EL.E-+SCTRt I'CisGnAL F
r-P-J,LrSrYUMBINGl-M,pEW+C'jH,-ANFIhEmCEf}AIT L
714
9
NAME 1 ✓ PLAN CHECK VALIDATIONLECIRIT QTY' y PHONE
CONT CTORG CUTLETS-SWITCHES-RECEP 5.00/1.00
NAM
LIC.No. LIGHTING FIXTURES 5.00/1.00
cONTRACTOR's APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS B QQ PLAN CHECK FEE P.C.NO.
oR
ENGINEER
Sec.NO. SIGNS TRANS. 3.00
ARCH.OR ENG' SPECIAL CIRCUIT 5-00
PERMIT VALIDATION
ADDRESS
zlv TEMP.METER OR POLE INS. 15.00
APPLICANT es MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00 �/C C�
o¢i aJ
F 02 LICIiNSED CONTRACTORS DECLARATION
Ie u I hereby alGnm that I am licensed under provisions of ChaPlcl9 ISSUANCE DATE
mrt i levmnieneing with Section 7000)of Division 3 of the Business and - BLDG. ELECT. PLG. MECH.
H m i Professions Cole,and my license is in full force and effect. ❑ ❑ El
o v,- License Class Lia Number
O F D DateContractor -
a y 4 i5�`It'?tBU_IL'DING'PERM T'
Q a w OWNER-BUILDER DECLARATION J`_ INFb 7107
A o A MISC.- REFER TO ORD #'` - _ _ A.
w3 LL H 1 hereby affirm that I am exempt from the Can Dactor's License VALUATION J S/FT,
r=o a Law for the fallowing reason.(See.7031.5.Businessand Professions PERMIT ISSUANCE 6.00
E Code:Any city or county which requiresa permit to construct.alter,
. , <0
improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIG rv0. ELEC.
-O a requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
wm he is licensed pursuant to the provisions of the Contractor's License { s j ,: ;1
zr
Law(Chapter 9(commencing with Section 7000)of Division 3 of the tt SrYu-2, 1rtg71 'I` 4i&,'$],IX?,ve21 '+b ` d:
E a Business and Professions Code)or that he is exempt therefrom J QT'yYba,�$y'a`.°TL'/) T `PLUMBINGe1rPERMIT FEE
F p the basis for the alleged exemption.Any violation mr Section 7031.$ y.ltt, ]N�4] r °-+dA14fTs2Y f�S �2iu �' STORIES TYPE CONSTR.
ate_ by any applicant for a permit subjects the applicant ma Civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of nut more than five hundred dollars(15000.):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sale compensation,will do the work,and the structure is not
intended or offered fur Sale (Sec. 7144, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND- 4.00
• Code:The Contractor's License Law dos not apply to an owner of
property who builds Or improves thereon,and who does such work F IXTUR ES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself Or through his own employees,provided that such improve- GAS-EA.SVSTEM-l 4.00
menu are not intended or offered for sale.If,however,the building
or improvement 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 im- RES IND CON PS Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
�%,1,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 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 fur such projects with a emittaclor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam excra under Sec. .B.&P.C.for this WATER HEATER W/VENT
rcamr
Owner_ Date WgTER SYSTEM ACC.DATE ACC.FILE NO.
RKF-RS'COMPENSATION DECLARATION WATER TREATING EQUIP. "4,q0
I hereby affirm that I have a certificate of eam cut to sell-m ure. AN ZONING ENG.SITE NO.
ar a certificate of Workers'Compensation Insurance,or a ccN icJ
copy thereol(See.3900.Lab Cd. ]BN ��� a;..
Policy No. Company 1 u
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-N
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. y N� Y 0 NC]
Applicant
I" y PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.c.
fL - CERTIFICA7'F:01:EXEMPTION FROM WORKERS'
w > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.TOTAL Y� N� Y❑ NF]
LL O IThrs Section need not be completed if the permit is for me
0 Z hundred dollars(SIOO)or less,) 3 1y
U O 1 certify that in the performance of the work tor which this per n '[' �,�y.- nkFEE' MA
QTY ,11{Ay aiMECHANICAL PERMIT Tr x FEE�}� krar
H mit rc issued,I shall not employ any pawn in any manner so as t a B'k il}pl„p �" x{ OiR`
LL Y..n,:r,efJw�Aa`4!".- 2 Jr
Qw lacunnesub(ect to Die Workers Compensation Lawsof Califormx BUILDING
Date-Applicant ALTER OR ADD TO MECH. 4.00
} m NOTICE TO APPLICANT: If,after making this Ccrlircam n(fix-
, F Z emption,you should haome subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
Provisions of tire Labor Code, you must forthwith comply with FEE
U Site[]provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.FM.) 5.00 SEISMIC FEE
1 hereby affirm Thal there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the p, louna ce of the work for which this permit is issued(See. MICROFILM
3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
. 1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
inlu.....tion is correct. I agree ro comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
ubuvrmcnti]med property I'or 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 pERM1T ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence of the
granting al'this permit. MEGs.CONT. LIC.NO. MECH. "�"',^•
TOTAL �•�I�.. y�7 "f
Sig ore of Applicuntj"ntraclor Date kss:".J4F?{F;yMv'
OFFICE COPY