5969 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT I DENT[FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
MADOREss BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 5969
D ME�z��M
i OWNERS PLAN CHECK VALIDATION
nAmE V/`CAj36-
j'ja'j _ (?(3_"7PRONE p7Y. ELECTRIC PERMIT FEE
NAME c7oRs UTLETS-SWITCHES-RECEP 5.00/1.00
NOME
ua'No. LIGHTING FIXTURES 5.00/1.00
cONTRACTORISPPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 5.00 DATE OF APPLICATION
RCRrtELT SIGNS B PLAN CHECK FEE P.C.NO.
O
OR
ENGINEER
LIC,NO, SIGNS TRANS. 3.00
AR. ENG. - SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDDDRESSSS
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANT'S MOTORS SEE FEE SCH. GP
ADDRESS
SERVICE CHANGE 10.00
BHD+
09 LICENSF-D CONTRACTORS DECLARATION o
< U u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
v, a N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F w z Protessions Codc,and my license is in full force and effect. ❑ ❑ ❑ ❑
Z o m- License Class Lic.Number
< m Date Contractor
c w a OWNER-BUILDER DECLARATION BUILDING PERMIT
IF-a U MISC.- REFER TO ORD INFORMATION
w 3 LL , I hereby attirm that 1 am exempt from the Contractors License 5/FT.
VALUATION
Fuoa Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 600
Code:Any city or county which requires.
equires a permit to construct,alter, .
Q Q improve,der n fish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEG /
- Ott requires the applicant for such permit to file a signed statement that TOTAL PERMITTO
e w m" he is licensed pursuant to the provisions of the Contractor's License '�pp
H z a Law(Chapter?(commencingwith Section 7000)of Division 3 ofthe VTU GGtl 'S
5 4 D Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
OF I the basis for the alleged exemption.Any violation af8eclion 7031.5 STORIES TYPE CONSTR.
s ;� by any applicant for apertnit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
of not more than five hundred dollars(S5000:
❑ 1,as owner ol'the properly,of 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 (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law docs not apply to an owner of
properly who builds or improve, 11CROn,and who does inch work FIXTURES-PER TRAP 4.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himselfor through his own employees,provided that such improve-
Incnis are not intended or offered for sale.If.however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4(EA.) 100 BUILDING USE
builder will have the burden of proving that he did not build or ice- . .
RES IND CON PB Other
prove for purpose nt sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,ant exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contrueton to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
End Pfolessions 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 cootractm s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ Iain exempt under Sec.-.BAP.C.for this WATER HEATER W/VENT 4.00
Own Dale WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPENSA'f1ON DECLARATION WATER TREATING EQUIP. 4.00
1 hereby ull'mo that I have i certificate of consent to set&insure. - ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(See.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby'furnished. FIRE SPRINK ENERGY T 29
Z 2 ❑ Certified copy is fled with the city inspection division. MISC.- REFER TO ORD.
D Applicant Y❑ N❑ Y ❑ No
W
CI:R'1 IF1CA'I'1i 01:EXEMP'T'ION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
UJ > COMPENSATION INSURANCE PLC.CONTR. LIC.NO. PLG.
CL p (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
D 2 hundred dollars(St00)or less.)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL h mit is issued.I shall not employ any person in any manner so as to /
U w bccolp}s t to the Workeri Compenwtion Laws of California. ��b
1cc BUILDING
Date`} _.Applicant ALTER OR ADD TO MECH. 4.00
} w NOVICIi'f0 APPI.ICANT: If,alter making this Certificate of 1!x-
F 2 emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you muss forthwith comply with FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10=C.F.NL) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000CEM.) 5.00 SEISMIC FEE �Z
I hereby of iron that them 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.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's AddresHEATI NG UN IT(OV ER 100,000 B.T.U.)7.50 ELECTRIC
s
1 certify that I have read this application and state Our the above VENTILATION FAN (SINGLE) 3.00
ordinancis n estate(.I agree to comply with all city ucti county BOILER-COW(3 H.P.or 100,000 B.T.U.) 4,00 PLUMBING
ordinances and Mnee laws relating to building construction, and
hereby authorise representatives of this city to enter upon the BOILER-COMP (Over 10,WOBTU)SEE FEESCH. 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 agal st aid City in consequence of the PERMIT ISSUANCE 3.00
ra�n(krJ/goo th' cn _ O MEC DBT. LIC.NO. MECH.
l / � J ( �y C/ /��/ TOTAL TOTAL ��7 61.
oSignalureor Applicant/Contractor [)are i
OFFICE COPY