5428 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
8011DIRD APPLICATION & PERMIT
ADDRESS 1
raOF cP�Ge eEC BUILDING - ELECTRICAL-PLUMBING -MECHANI'C<AL 5428
OWNER'S " - � {�rly'� PLAN CRE VALIDATION
a NAM QTY::: •-,-.•: ELECTRIC PERMIT, ijr�" ^'T'•. FEE- C� 5
. PHONE
CONTRACTOR S OUTLETS-SWITCHES-RECEP 5.00/1.00 S 3S�� }°
NAME
L VL4LIC.NO. LIGHTING FIXTURES 5.00/1.00 4❑'
1 aoo ess roll's v �'] PPLIANCES-RESIDENTIAL 4.00
2 ry7A JI�I (t PRONE 6-) 9 PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR \
ENGINEER /OrJ(.(�.('
uc.No. SIGNS TRANS. 3.00
ARCH.OR END SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ADDREss
ZIP rFEMP.METER OR POLE INS. 15.00 /
APPLICANTS MOTORS SEE FEE SCH. 5 V
ADDRESS
SERVICE CHANGE .00
0 0 o LICENSED CONTRACTORS DECLARATION
X u e~a I hereby affirm Thal I am licensed under provisions of Chapter 4 1Qi ISSUANCE DATE
o
m w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F w z Prokssions CoJ• Ic
aqJ m feense is m full for d I. _
z 0 - Litenx Claw-�-+ - Lic.NI - r% y 8 UDErtlflLa I �
O m t 0 Dat Contract
B L ERMIT -
a w a
OWN
IT
.R D CLA 10 - -
¢ u @INFORMATIONo• :•=
w ; a r I hereby affirm that I am exempt from the Coruractoh License MISC.- REFER TO ORD
LLo JLaw tin the following reason.(Sec.7031.5,Buslnessand Professions PERMIT ISSUANCE 6.00 (,'y{, ftyATI�N SIFT.
Codc'.Any city or county whichrequiresa permit mconstruct.Ater, l� �O�
¢ T rt O nrprove,Lieanolish,err repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. /
- O ¢ mulles the'npplicunt for such permit to file a signed statement that TOTAL V'
a w m LL he is licensed pursuant to the provisionsol'the Contractors License v_ �9 A ;y
iii
Law(Chapter 9lccmmemongwi[h Section 70001o1'Division 3 of the s -FE \ //'.b'rUII�J"�
a Business unJ Professions CoJel or that he is exempt therefrom and QTY. .',PLUMBING PERMIT... q E'
Tet $ the basis I'or the alleged exemption.Any violation of Section 703 L$ - STORIES TYPE CONSTR.
c' by arty-PPhcanl for a permit smite the applicant macivilpenalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars 6500).1:
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their snle compensation,will Jo the work.and the structure is not
untended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Cole:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 SO.FT.RLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such improve- GAS-EA.SYSTEM-11NC.40UTLETS 4.00
monis are not intended or offered for sale.If,however,the building
or improvement is said 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 im- Ey ❑ O
IN Or
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 rrCsJS
❑ I,as owner of the properly.am exclusively contracting with ❑ ❑
license contractors 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 2 L el-//I ' OI z
to nn ,.net of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 J J / / (-, f
coitrvcls forsuch projects with a contractm(s)licensed pursuant to SEWER-SAN TORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ I am exempt under Sec. .B.&P.C.for this WATER HEATER ENT 4.00
lc'li n
Owner Date WATE EM2
4.00 ACC.DATE ACC.FILE NO.
WORKFRS'COMPENSATION DECLARATION WATER TREATING tt P. 4.00
I hereby affirm that I have a certificate of consent to self-insure. CI ZONING ENO.SITE NO.
certificate of Workers'Compensation Insurance,or A Certified
copy ther• II 800.Lab C.). b /r If -
�• Policy Nn jQ_Lcj(Company- 4T N IL
Q ❑ Certified copy is hereby'furnished. FIRE SPRINK ENERGY T.20
Z Zf1 Certified y is filed s -h e <i inspection division. MISC.- REFER TO ORO. v N v N�
F 01_ :\PPlicant_ '
w CFR'ITFICAMOFFAEM PTIONFR WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.O.
111 > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. 0 s
CL OTOTAL M❑ N❑ YC] No
(dre sectionr, need not W completed it the permit is for one
0 Z hI nil I toilers 1 n the pe form. i
- I
U O I certify that 'n the Performance of the work for which this per QTM': 1'MECHANICAC•PERMIT• �- .+ ' ': FEE`i•' f DING
Z UIiMAARYr q 'u},
17 mit s issued,I shall not employ any person in any manner so as to {:� rQ wbcnnu•xihject to the Workers'Compensation Laws ofCalifornia. BUILDING �Q SZItuln Applicant ALTOR ADO TO MECH. 4.00
rno NOTICE '1O APPLICANT: If,after making this Certificate of Ex- 4.00 PLAN CHECKeruption,you should become subject to the WorkersCompensation APPCEprovisions d the Labor Code, you must forthwith comply with qIR DLING UNIT(TO 10,000C.F.M) 3.00 FEEsuch provisionsor thispermit shall bedeemed revoked.CONSTRUCTION LENDING AGENCY AIR DLING UNIT(OVER 10=1C.F.M.) 5.00 SEISMIC FEEI hereby affirm that there is a construction lending agency for EXT HOOD(WITH DUCT) 2.00 MICROFILM
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00
3097,Civ.C.).
Lender's Name HEATINGUNIT(OVER 100,000 B.T.U.17.50 ELECTRIC � (u
Lenders
Address
1 certify thm I have read this application and state that the above VENT: INGLE) 3.00 PLUMBING /Q
information is correct. I agree to comply with all city and county BpILFR- 13 H.P,or 100,000 B.T.U.) 4.00
ordinances and stale laws relating to building construction, and
hereby authorise representatives of this city to enter upon the BOILER P lav 1 TUI SEE FEE SCH. MECHANICAL
nhove-mentioned properly for inspection purposes.
(Wel agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities, adioncills, costs and expenses which
PERMIT Upe IOU 3.00 _ CONST.TAX
4yi
anywayac'ereaganst s' City iyonx uensk j[he
ofthperm �"`�-_gMECH.CONT. LIC.NO, MECH.roTALTOTAL"E' . 7'�
c o Appb antlContraclor Uate /
OFFICE COPY