6921 AL,$;PLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDINGS APPLICATION & PERMIT
aorE s
i(fG44f6L6aW RL' BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 6921
O rvE 'S PLAN CHECK VALIDATION
NNA1ME f/�y/ 1 119-37Y-Q6 OTY. ELECTRIC PERMIT FEE
0ORIS Ay
CONTRACTORS UTLETS-SWITCHES-RECEP 5.00/1.00 -T/T)
/NAME
6MJdl< LIC.No S5o8 LIGHTING FIXTURES 5.00/1.00
CONTRACTORS pq<e e �` PPLIANCES-RESIDENTIAL 4.00
ADDRESS
O 1I1(- PHONE p PANELS 5.00 DATE OF APPLICATION
ARCHITECa - SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENCI [R LIC.NO. SIGNS TRANS. 3.00
ARCH.UP ENG, C
G SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS �k7[�'�Q
OQ - zIP 0 EMP,METER OR POLE INS. 15.00 ,
ADDRESS r'S MOTORS �aQgc/; SEE FEE SCH.
ADDRESS
(E SERVICE CHANGE 10.00
0 O LICENSED CONTRACTORS IIECLARA'fION
< v w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DAT
w Z y conunenemng with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
v,w z Pmlessions CoLL a d my f)c9nse is in full force II t (1 r(� T
z O m- .icenu G dL(_•�Lic.Number.`.4-y77qa,,Id�yrl ❑ ❑ _ ❑ ❑
ay Ualel. � `� ConlraCtnr_t�lC/ f
¢ ¢ ¢ OWNFR-BIIILDF"R DECLA�rRAATIION` ri!It r.L fs,....41 ,. BUILDINGORMATION
aOw " MISC.- REFER TO ORD . ( INFORMATION
w 3 u m I hereby'affirm that 1 am exempt from the Contractors License VALUATION' $/FT.
F .. O a Law torr the following reason.(Sec.703 L$,Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,alter, 30 d..dr0
ac 2 ¢ improve,demolish,or repair any :prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
-O u requires the applicant for such permit to file a signed statement that TOTAL •y vIpERMIT,TO nD
X w he is licensed pursuant to the provisions of the Contractors License
HiQ
Law(Chapter 9(coninencing with Sect ion 7000)of Division 3 of l he SaLeae
4 D Business and Puricso one Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ e the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
A. T by any applicantfor a permit subjItCPHIC applicant tea Civil penaltyr11:1
ALTER-DRAIN& VENT-WATER (EA.) 4.00
of not more man five hundred dollars(S500).):
❑ I,as owner of the property,or my employees with wages usBACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sols compensation,will do the work,and the 1,ructure is not
intended nr offered In, sale (Sec. 7044, Business mal ProfessionsDRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner o1'
properly whin builds or improves thereon,and who does such wellFIXTURES-PER TRAP 4.00 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve
mentsare not intended or offered l'or sale.If,however,the buildingGAS-EA.SYSTEM-11NC.40UTLETS 4.00
or impmvcment is solA within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the bunlen of proving Himt he did not build or int- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ 1,as owner of the property am exclusively contracting with ❑ ❑ ❑ C]licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B.' 5.00 ASSESSORSPARCEL NO.
and Professions Code:The Contractoh License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERSfIOVER,5(EA.) 1.00
contracts for such projects out,a contmetonO licensed Pursuant It,
the Contractor's Lice use Law. SEWER-SANITARY-STORM 'EA./
200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 um exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT _ 4.00 xx
reaOwner [)are WATER SYSTEM lana •n • •"'4.00 ACC.DATE ACC.FILE NO.
WORK Ii RS'COMP17NSA'1'ION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure. _ ZONING ENG.SITE NO.
-/ or a eellificale of Workers'Compensation Insurance,or a certified
T copy them-SOD,Lab.C.).y ��
Policy No ( ompanY_
Q ❑ Certilicd copy O hereby furnished. FIRE SPRINK ENERGY T-74
Z z ❑ CCrtificd/.'o is !- I wytrm the city insPeclion division. MISC.- REFER TO ORD. Y ❑ N❑ y ❑ NO
F O APPlicenf �� `jam-.L�
CC > CF. IFICKI'E OF HXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
_ COMPFNSATION I NSU RANCG
W PLD.CONTR. ❑C.No. PLG, C/U
CL O (This section need not be completed if time peril is for one TOTAL U ` Y❑ N❑ V 0 N
Z) Z hundred dollars IS 100)of less.)
U O certify mal in the perfunn:mce of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall nut employ any Person in any manner so as to
OW bvunne subject to the Workers'Compensation Laws of California. BUILDING xg GO
Date Applicant ALTER OR ADD TO MECH. 4.00
}
to NOl'ICE TO APPLICANT': If,after making this Certificate of Ex-
crop'ion,
x-
crop'ion,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
P
rovisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10PMC.F.M.) 3.00
CONS1'RUCI ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE OZ /
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT ATO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that 1 have read this application and stale that fila above VENTILATION FAN (SINGLE) 3.00 dtJ
information u correct. I agree to comply with all city and county BOILER-CONN(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING Q
ordinances and stale laws relating to building construction, and
hereby i mthorim representatives of this city.to enter upon the BOI LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-inentioned 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 accnme a pppainst s ' City in consequence of the PERMIT ISSUANCE 3.00
granting Of this peril. // MECH.CONT. LIC.NO. MECH.
/ TOTAL TOTAL `/ �O
Si,4cl&A plica rut/Contin ar Uatc
OFFICE COPY