4594 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
aG,pLP°,NG APPLICATION & PERMIT 4594
Ate/ s 1� oneoVI� BUILDING —ELECTRICAL—PLUMBING—MECHANICAL
•OWNER'S •l U PLAN CHECK VALIDATION
EJ.fj. QTY. ELECTRIC PERMIT FEE
PEON
N° rRAcrORs UTLETS-SWITCHES-RECEP 5.00/1.00
a5RgnaeALIC.NO.137L;)5LIGHTING FIXTURES 5.00/1.00
E rRAcro
A RLH
PPLIANCES-RESIDENTIAL 4.00
MWr&d
ONE
PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS B.00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER
LIC,NO. SIGNS TRANS. 3.00
ARCH.OR
RESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP. METER'OR POLE INS. 15.00
ADDRESS CC
APPLICANT MOTORS SEE FEE SCH. J
ADDRESS
SERVICE CHANGE 10.00
0 0 o LICENSED CONTRACTORS DECLARATION I/A
a E,u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w Q WAi (commencing with Section 7000)of Division 3 of the Business anti BLDG. ELECT. PLG, MECH.
E. o zuProfessions Cod n icense is in full for
z O H — Licen ;g " Con ractor ❑ ❑ ❑
ow w Dare Contractor
¢ s, s BUILDING PERMIT
a w u OWNER-BUILDER DECLARATION INFORMATION
stod MISC.— REFER TO ORD
; w I hereby affirm that I am exempt from the Contractor's License
Fco J Law for the following reason. 7031.5,Business and Profession's PERMIT ISSUANCE 6.00 VALUATION SIFT.
W Code:Any city or county which requires a permit to construct,alter.
2 ¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CDNTR. LIC.NO. - ELEC.
at G, requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w$ he is licensed pursuant to the provisions of the Contractors License
Fi> Law(Chapter 9(commencing with Section 70DO)of Division 3 of the
i c Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
a H the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
s- by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(5500).1:
❑ I,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
I ropdrty who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
Imself or through his own employees,provided that such improve-
Ientsarenot intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
r improvement is sold within one year of completion,rhe 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-
for RES IND CON PB Other
prove 1,aso nee of sale.l; INDUSTRIAL WASTE INTER. 20.00 ❑ � ❑ ❑
❑ d as owner of the property,he exclusively contracting with
licensed contractors: construct the project(Ste 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not iwho
ce tr owner of property who builds to improves licensed
rased u and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
son Cods for such projects with a contortions)licensed pursumH to
the Contractor's License law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under SEL.—,B.&P.C.for this WATER HEATER W/VENT 4,00
reason
Uale Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure, `
or a certificate of Workers'LabCom nsation Insurance,or aNte�rrified ZONING ENG,SITE NO.
copy they ,,p,ny
Policy Ipany +
0 ❑ -rli led Copy 151Creby furnished. FIRE SPRINK ENERGY T-24
Z Z rif Cerrif < o y 1 +led with the ci inspection division.
O Applicant � MISC.- REFER TO ORD. Y EJ N❑ Y❑ N❑
CC to CE RTI FICATE OF I:X EM PTION FROM WO RK Ii RS' PERMIT ISSUANCE 5.00 FLOOD ZONE A.L.O.C.
W L COMPENSATION INSURANCE: PLG.CONTE. LIC.NO. PLG.
CL Z (This section need not be completed if the permit is for one TOTAL Y N Y N❑
hundred dollars IS 100)or less)
U 0 I certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers Compensation Laws of California.
y Date ApplicantALTER OR ADD TMH. ' 4.00 BUILDING
>_ to NOTICE TO APPLICANT: If,after making this Certificate to fix
? emption,you should become subject to the Workeri Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
V Stroh provisions or this permit shall be deemed revoked AIR HANDLING UNIT IT 10 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction leading agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I have read this application and stare that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county - PLUMBING
-gnlinances and state laws relating to building construction, and BOILER-OOMP(3 H.P.or 100,000 B.T.U.) 4.00
• mby authorize representatives of this city to enter upon the BOILER-COMP (Over(00,000 TUI SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City I' FER TO ORD.
Cupertino against liabilities,judgments, costs and expenses whit 1 PERMIT ISSUA CE 3.00;5,()VCONST.TAX
ma in any way accrue against said City in consequence of the
gra lin o this per it MECH.CONT. -LIC.NO. MECH.
YOU 7 x�j��p� �p /f�� TOTAL
gnatureo Applicant/Contrnur� Date LyJIs/+•Ie&Fsal,r,.a 13105 �DD TOTAL
OFFICE COPY