4598 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL- POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT 4598
AOOness
BUILDING -ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME
1 P GNE
5 �, ' QTY. ELECTRIC PERMIT FEE
CONTRACTORS OUTLETS-SWITCHES-RECEP 5.00/1.00
NAME L
J1 'LIC.NO.,e � LIGHTING FIXTURES 5.00/1.00
CONTRACTOR APPLIANCES-RESIDENTIAL 4.00
AOOREss C
3 2 o ek- HONE 270 222 PANELS 5.00 DATE OF APPLICATION
4RCHITECT SIGNS 6-.00 PLAN CHECK FEE C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH,OR ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ADDHESS
ZIP EMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
wo o LICENSED CONTRACT ORS DECLARATION 1"&)Ted-r e-C [Z I
¢ v w I hereby affirm fiat I am licensed under provisions of Chapter 9 ISSUANCE DATE
w< m (commencing with Section 7000)of Division 3 of the Business mail BLDG. ELECT. PLG. MECH.
H N z Professions Code,.m ry license is in full force p yJf LL L / l C✓
z o m - Liccnso C ass Lic.Number GL LG ❑ ❑ ❑
D 0 H w ata �' Cont tactor -
`a BUILDING PERMIT
¢ ¢w OWNER-BUILDFR DECLARATIO, INFORMATION
w 3¢ y 1 herebyaffirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
1y4LUATION $/FT.
is LL o a Law for the following reason(Sea 703 t.5,Business and Posl'exsions PERMIT ISSUANCE 6.00
Code:Any city or county which requires o permit to construct,aher.
¢ ¢ st 00 improve,demolish,or repair any structure,prior to its i,,Uuncq also ELEC.CONTR. LIG.NO. ELEC.
at D ¢ requires the applicant for such permit to file a signed statemmv that TOTAL ry yyERMIT TO
¢ w m¢ he is licensed pursuant to the provisions of the Contractor's License 7,.,,, � 'd
t
a,s- Law(Chapter 9(commencingwith Section 7000)ofDivision 3 of the l 'dG
a Business and Professions Code)nr that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ o the basis for the alleged exemption.Any violation of Section 7031.5
/sr, TQrj1ES- TYPE CONSTR.
ac by any applicant tin a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
tatyppgtjnfj
of not more than five hundred dollars(S500).l:
❑ 1,as owner of the property.or my employees will,wages as BACK FLOW PROTECT.DEVICE 2.00 0 o S.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
property who builds or improve,thereon,and who does such work F IXTURES-PER TRAP 4.00 sD.FT.FLODR AREA TOTALACHEAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-11NC.40UTLETS 4.00
clients are not intended or offered for sale.If.however.the building
br 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 int- RES IND CON PB Omer
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 20.00 El El El ID ❑'
0 1,as owner of the property,ant exchtsivaly contnmting with
licenud conmeturs 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 for such projects with a eontractonxl licensed pursuant to
the Contractor's License Law. WEERITARV-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sea ,B.&P.C.Gsr this WATER HEATER W/VENT 4.00
pson
ate Owner WATER SYSTEM 4.00 TCC.DATE ACC.FILENo.
WORK ERS'COMPFNSKI'ION DECLARATION WATER TREATING EQUIP. 4-00
1 hereby affirm that 1 have a certificate of consent to scltvinsure, ZONING ENG,SITE NO.
or certificate of Worker,'Con,petn iap Instt rultge,or a certified
copyttemoyf5 l o!,L�,c.). SAT S
Policy No. o pony
Q 0 Certified copy is hereby furnished FIRE SPRINK ENERGY T 24
Z s f dvltlr tyE city inspection Jivisigfi. Y ❑ N❑ Y ❑ N❑
O Applic❑ antCertifie +'.� �f - MISC.- REFER TO ORD.
CC PERMIT ISSUANCE 6.00 DO ZONE A.L.O.c.
N
LU ] f-ERTII'ICCO' P Is I AK IO PION PROM WURKIiRS'
W COMI'ERSAI'ION INSURANCE �-- PLG.LONTR. LtC.NO. PLG.
d 0 (Phis section need not be completed if the permit is tot one TOTAL Y❑ N❑ v ❑ N❑
Z) Z hundred dollar,($100)of less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
mit is issued, I shall not employ any person in any manne,V1 as to
O W become subject totheWork ecs'Compensation Laws ofCalifornia. BUILDING 3�sv
Date Applicant ALTER OR ADD TO MECH. 4.00
} y NOTICE TO APPLICANT: If,alter making this Certificate of Ex-
emption,you should become subject to the Workers'Compensation 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(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,00DC.F.M.) 5.00 SEISMIC FEE
1 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,Co.C.). HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name HEATI NG UNIT(OV ER 100,000 B.T.U.0.50 ELECTRIC
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and countyPLUMBING
c.ulinances and state laws relating to building construction, and
BOILER-COMP I3 H.P.or 100,0000.T.U.) 4.00
hureby aullionie representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property I'or inspection purposes.
(We) agree to save, indemnify and keep hurmlcss 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
granti golthus crtniL � ' / MECH.CONT. LIC NO. MECH.
f/` /A, Tornl TOTAL
Signature of Applicant/Contruc Date
OFFICE COPY