3489 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON PE MIr E
aaILOIN APPLICATION & PERMIT 489
A07RE
O _ L ✓ BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
CANNER 5 '• " ' PLAN CHECK VALIDATION
P7 -Y-¢y TY. ELECTRIC PERMIT ..r - '.FEE
PHONE
• CONTRACTORS UTLETS-SWITCHES•RECEP 5.00/1.00
ME 1 Zlr�ssd
r /MVfm1 S � LC.NO. LIGHTI NG FIXTURES 5.00/1.00
CONTRACTORS f a.s APPLIANCES-RESIDENTIAL 4.00
ADDDRREEkss A.' / ,,/y�� [ q♦3-LT
�L_�r�G/� [J�THONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
zlv TEMP.METER OR POLE INS. 15.00 =/19
ADDRESS is MOTORS SEE FEE SCH. /u/, 06((//��iF/]
ADDRESS
SERVICE CHANGE 10.00
o o LICENSED CONTRACTORS DECLARATION
Q U U 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
h< N (commencing with Section 7000)of Division J o(the Business and BLDG. ELECT. PIG. MECH.
s-m z Professions Cod,an y license is in full force a �fe �� ❑ ❑ ❑
z 0 m - Licens ss �- Lic.Number r
Q L r w Date Contractor.
a V 2 •;r_,",BUILDING PERMI:r,e4- 4r
IC M W< OWNER-BUILDER DECLARATION 1''i''i;.IINFORMATIONI'v•?'.H,p i
D REFER TO ORD ' '-
m ; 1 hereby affirm that I am exempt from the Contractor's License MISC.-
uOa Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE VALUATION S/FT.
� y Cade:Any city or county which requires a permit to construct.alter.
6.00
ics Q FO improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
0 0 u requires the applicant for such permit to Zile a signed statement that TOTAL P MIT O
w2 a he is licensed pursuant to the provisions of the Contractor's License -, _ _ / /r�jyT
Fi > Law(Chapter 9(commencing with Section 7000)of Division J ofthe I - +• ` -'r'. •-ft. _ ' I+9TT
< Business and Professions Cade)or that he is exempt therefrom and OTY: PLUMBING PERMIT '+ ''FEE •
tt o the basis for the alleged exemption.Any violation of5ection 7031.5 . ''s ' 'L• ' ..La ' ':�' "+� I TYPE CONSTR.
A. ; m by any applicant for a permit subjects the applicant too civil penalty
ofnot marc than five hundred dollars 15500).): ALTER-DRAIN (EA.) 4.00
❑ 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
property who builds or improves thereon,and who does such work FIXTURES•PER TRAP 4.00 S6 FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
' merits are not intended aroffered for sale.If,however.the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner. GAS-EASYSTEM-OVER 4 (EA) 100 BUILDING USE
builderldc,will have the burden of proving that he did not build or im. . . . RES ND CON PB On.,
prove for purpose of the.). INDUSTRIAL WASTE INTER. 20.00 �❑ ❑ ❑ ❑
❑ d c owner of the property,he exclusively contracting with
licensed contractors to construct the project La 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL No.
and Professions Code:The who
builds
License Law does not apply
to tr owner of property who builds tr improves thereon.and who LAWN SPRINKLERS•OVER 5(EA.) 1.00
contracts for such projects with a contm,torl sl licensed pursuant to
the Contractor's License law. SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO. PARCEL NO.
❑ (am exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 4.00
reason
Data Owner WATER SYSTEM 4.00 WCC.-DATE ACC.FILE NO.
WORK ERS'COMPF.NSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure.
or a certificate of Workers'Compensation Insurance.or a certified ZONING ENG,SITE NO.
copy thereof(See.3800.Lab.C.). /I//��
Policy Company ��(
O Rtllied Copy is hemby furnished. FIRE SPRINK ENERGY T.24
❑ Certifi copy is filed wiN the cit inspection division.
Z Cr Applicant MISC.- REFER TO ORD. y❑ N❑ Y ❑ IN
Hy PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LuCERTIFICATE E SATIONI FROM WORKERS'
W � COMPENSATION INSURANCE PLG.CONTR uc No. PLG. � Y N Y N
D' (This section need not be completed if the permit is for one TOTAL ❑ ❑ ❑ ❑
U O hal eerttify tred 1ars IS hat in het or performance of the work for which this per- Ir' ti .FEE.SUMMARY
Iy mil is issued,l shall not employ any person in any manner so as to DTV. MECHANICAL PERMIT 4 ^ L7L s FEE LB 1 - .- 1 . .✓..:
O Ubeco u c tp the Workeri(79*enution Laws of C 7lifarni
LU DazeL Applicant ALTER OR ADD TO MECH. 4 00 BUILDING
>_ N NOTICE TO APPLICANT: If,after making this Certifical Ex- ~ c, ^
emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN ff�f 'N1V
provisions of the Labor Cade, you must forthwith comply with FEE o� 0
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=11F.M.) 5.00 SEISMICF E add
I hereby affirm that there is a construction lending agency far EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICR ILM
3097,Civ.C.).
Lender's NameHEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC p
LECTflIC '
p Fa
Lender's Address
I certify that l have read this appliewionand state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.Dr 100,000 B.T.U.) 4.00 PLUMBING 0
ordinances and state Taws relating ( building ,onster eon. and
hereby enthorite representativesertfrns of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCM. 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 PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence of the
gran 'ng of l his permit. 1 wa Q.�. MECH.CONT. LIC.NO. TOTAL ��•{TOTAL`I�'Y� /�
Ignatur of Applicant/Contractor Date aCJ _ >C•. p
OFFICE COPY