5737 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY
/ BU I LDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BaILDmG APPLICATION & PERMIT 5737
a ORL55
CIZ3 IVO✓ Ger �r BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'SM-a PLAN CHECK VALIDATION
• "AME •TV. 'ELECTRIC PERMIT `, '� F EE
PHONE
CONTRACTORS It UTLETS-SWITCHES
AM -RECEP 5.00I7.00
NAME n ^
/CalI Po C, 1`" •• Ic.No.�xj-So LIGHTING FIXTURES 5.00/1.00
CONTRACTOR PPLIANCES-RESIDENTIAL 4.00
ADDS ESS
C4
G14 Z'il �r;,•N,••••(1- ylylyLiNE(J� �:j PANELS 5.00 DATE OF APPLICATION
ARCHITECTSIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS EN¢ SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ASOSEss
ZIP rrEMP.METER OR POLE INS. 15.00 n
AvvLlcarvTsSEE FEE SDH.
MOTORS
ADDRESS I
• SERVICE CHANGE
00 LICENSED CONTRACTORS DECLARATION IG Ue l
v U I hereby affirm that I am licensed Under provisions of Chapter 9 ISSUANCE DATE
y <d (commencing with Section 7000)of Division 3 of the Business and _ LO ELECT. PLG. MECH.
Professions Code I or is in full l'orS4 -ffcctt. ❑ ❑ ❑
z o w Li,.se Claus IAc.Numhcr
am Date_(J-��¢ (-Contmctor_/i90- t
IC a w¢ OWNER-BUILDER DECLARATION BUILDING PERMIT -
o A O MISC.- REFER TO ORD INFORMATION
w3 ,�y 1 hereby affirm that I am exempt from the Contractors License VALUATION $/FT.
F LL o a Law lasin
r the following reason.(See.7031.5,Buessand I'fol' o
essins PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to const rueL Shea
KR ¢ O improve,denmlish,of repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O LL requires the applicant for such pernin to file a signed statement that TOTAL PERMIT TO
R
$ he is licensed pursuant to the provisions of the Contractor's License
r z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
G Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r es the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant I..a permit subjects the applicant too civil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00 C/
of not more than live hundred dollars(5500).1: LI
❑ 1,us owner Of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2,00 SCC.GROUP RES.UNITS
their sole compensation,will It -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:'1'Iie Contractor's License Law docs not apply to an owner of om
property who builds or improAs thereon,and who does such work FIXTURES-PER TRAP 4.00 sa.FT FLo AREA T TAC ACREAGE
hinhself or through his own employees,provided that such in.prose-
Dents ate not intended orofferedfor s,Ic.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement Is wild 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 Sir inh-
pravefor Purpose of.lv.). INDUSTRIAL WASTE INTER. 20.00 5 IND CON PB Omer
❑ h 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 rhe Contractor's License Law does not apply
to m owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contruclons)licensed puntmnt 10
the C...OmeWrf License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
❑ lam exempt under SScc. .B.&PEC.ter this WATER HEATER W/VENT 4.00
Scala,
Owner Date WATER SYSTEM 4.00 ACC.OATE ACC.FILE NO.
WORK ERS'COMPFNSA'I'ION DECLARATION WATER TREATING EQUIP, 4.00
I hereby atfimu that I hove a ertil'ic,le of consent to lel Ginuve. ZONING ENG.SITE NO.
or a cerlifcat of W kcrd Compensation Insurance,or u certified
copy thcrcof ab.C.).
policy Nn.l�any_ga�,q!
O ❑✓Corti tied copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ^Certificd4 tihPya i fled h D pecton division. MISC. REFER TO ORD. y N y N
O Applicant [.Ci ` dr9K� ❑ ❑ E] ❑
CC T CER'1'IIICA'1'C Op I:XFMP1'[ON FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
W > COMPFNSATION INSURANCE PLG.CONTE. LIC.NO. PLG. ,
(L o ITbis section need not be completed if the permit is for one TOTAL V E] NE] V ❑ N❑
::) Z hundieddollms(5100)or less.)
U O I certily that in the performance sof the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any manner so as to
Ow becoma subject to the Workers'Compensation Laws of Cahlorria. BUILDING
Dom Applicant ALTER OR ADD TO MECH. 4.00
>- h NO'I'WE '1'O APPLICANT: 11,after making this Certificate of Ex-
F Z eruption,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)000C.F.M.) 3.00
CONSTRUCT ION LENDING AGENCY. AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE
I hereby affirm that Ihere is A cunslnhclion lending agency fur EXHAUST HOOD (WITH DUCT) 2.00
the perfurnhance of the work for which this permit is issued(Sec. MICROFILM
3097,0,C), HEATING UNIT(TO 100,000 B.T.U.) 4.00
Leader's Name HEATING UNIT IOV ER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
adonnation is correct. I agree to comply with all city:Ind County BOILER-COMP13 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construe inn, and
hereby authorize representatives of this city m enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above.mentioned properly 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 PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence of the
gmn% of I is pern� MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
„
Signature of Applicant/Conlmetor DatIe
OFFICE COPY