5513 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
BUILDING PROJECT IDENTI FICATIL-..
ADooREss APPLICATION & PERMII
DRESS O
Z I BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OwNEP'a .Axs ... �S Cis yy�n'n,. tbtr,+ y �,Cy PLAN CHECK VALIDATION
5 513
"AME �aBLECTRIC'PERMIT✓ , ( S
PHONE 'S x`a'.`�':atld H:
CON TRACTOR S7
NAME -�!�/ UTLETS-SWITCHES-RECEP 5.0011.00
C-50,L) 1ZOLC'62 LIC.No LICIT LIGHTING FIXTURES 5.00/1.00
DDNTRAcADDRESST.R� PPLIANCES
-RESIDENTIAL 4.00
�J �p1 r
1J' h�r(� PHONE ^ PANELS 5.00 ,5� DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE D.C.N0.
O
OR
ENGINEER
C.No. SIGNS TRANS. 3.00
ADDRRESS ENG' SPECIALCIRCUIT PAI 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTSMOTORS SEE ,§CH.
ADDRESS
SERVICE CHANGE 10.00
'02 LICENSE CONTRACTORS DECLARATION MY of Cu of ' /
¢ u u I hereby affirm [hat I am licensed under provisions of Chapter 9 ISSUANCE DATE
w "' )commencing with Section]000)of Division 3 of the Business a
a H BLDG. ELECT. PLG. MECH.
H D z Professions Code, my license is in full fore el et
License CL�/s- Lic.Number ,
o m H Date.d(1_- _ Contractor_
¢ o a u _F!/VOW .R-BUILDER DECL R TIO 14 Ip�'Pg10N�i�,
w AT
3 LL w 1 hereby affirm that 1 am exempt from the Contractor's License ]MISC.- REFER TO ORD VALUATION I FT.'
Fu0a Law for the following reason.(Sec.703 1.5,Businessand Professions PERMIT ISSUANCE 6.00
Code:Any city or E.Enty whichrequiresapermittoclostruct,seller. h��I(
a a,Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. EIEC. L �. ! S o /& a "r p//�ynr Uol)
K q
m ¢ requires the applicant for such permit to file a signed statement that TOTAL l0 PERMIT
w he is licensed pursuant to the provisions of the Contractor's License T �
F, 'a Law lChapter q(commencing with Section 70001of Division 3 ofthe Sb,}rf„ t F�"I 1•s'3'1-11'pz4? =1 V^ q�. fA1(l q 't ++:,�. f/1/(t.'l..fr ,
zo Business and Professions Code)or that he is exempt therefrom and DT`V' PLUMBING FBRMIIT, '(k „r 11 9IF'`.
¢ H the basis for the alleged exemption.Any violation of Section )-�n.,.w��`.r1•',.TPN: 3.1� I;.r�'Y'rs if(1tL(wL. STORIES TYPE CONSTR.
n ; by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER IEA.) 4.00 Nr f'fZ
of not more than five hundred dollars 1$500).1 9
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 DCC.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 - 3 /
• Code:The who
r License Law does not apply to an owner of -
himsersy who builds or improves thereon,and who docs such Work FIXTURES-PER TRAP 4.00BO.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such improve-
munprosnemisnoldoroffered forsale.lcompleveq thebuilding GAS•EA.SYSTEM-1INC.4OUTLETS 4.00 a(p ,(�
or Improvement is sob within one year of completion,the owner GAS•EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not bulb or im-
prove for purpose ofs41e.). INDUSTRIAL WASTE � 20.00 RES IND CON PB 011.1L owner
❑ as owner of the properly, exclusively contracting with [:] ❑ ❑ E] [:]licensed contractors to construct the
protect(See.7044,Business
to LAWN SPRINKLERS-1 INC 5 V.B. 5.00 _ ASSESSORS PARCEL NO.
Professions Code:The Contractor's i License Law does not apply
m ann owner of properly who builds or improves thereon.and who LAWN SPRIN KL R 51".9 1.00
contracts for such projects with a contmctons)licensed pursuant to SEWER-SAN ITAR -STORM EA. 200ft/8.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ 1 u
H."on In exempt under Sec. B.&P.C.for this WATER HEATEM R
Cu ertmo 4,00
Owner Date WATER SYSTE4.00 AGC.DATE ACC.FILE NO.
WORKERS'COMPENSAI'ION DECLARATION WATER TREATING EQUIP. 4.00
I hereby aform that I have a certificate of consent to self-insure,
ZONING ENG.SITE NO.
o�r7/y�-}V�{t iff If rtsJ^'a�wsnrperz��ilt/ieA11 surance,or a certified
T I',Acy-Neu c- Compuny�L'✓/ I 9 r
O ❑ Certifie copy is hereby furnished. FIRE SPRINK ENERGY ]4
❑ Cert' ed y is tiled h the city inspect
z00 Applicant C.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
� y CER'PI FICATE OF EXEMPTION FROM WORK ERS' PERMIT ISSUANCE 6.00 G FLOOD ZONE A.L.UA.
LU5 COMPENSATION INSURANCE PLG.CONTE, LIC.No, PLG. Y❑ N❑ Y ❑ N❑
CL 0 fibis section need not be completed if the permit is for one TOTAL
hundred dollars 151001 or less.) c to u r y� (tia'�.vF tH v smka 1
V O I oily that in the performance of the work for which this per, d .ju. "`� ys�'�. ' � Q'8{JIIIp1�A{Is/ n' 'S
CIT w MBCNANICAL PBNMITy,� R86B 4 '5.,�
UL H colt H issued,I shall not employ any person in any manner so as to „y _ y y...1,s q .L^Rn N'
U become subject to the Workers'Compensation Laws of CaRforma. BUILDING p M
y nate Applicant ALTER OR ADD T 4.00 3
} W NOTICE. TO APPLICANT: If,after making this Certificate of Ex-
I- Z emption,you should become sutijeut to the Workeri Compensation App LIANCE 4.00 PLAN CHECK
prosisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR H V DLI T( 10 .M) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLI III ER 1000C.F.M.) 5.00 SEISMIC FEE Z 766
1 hereby affirm that there is a construction lending agency for EXHAUST HO 1 I 2,00 -i
31097 Civ C.j° ace of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.P.50 .��
Lender's Address ELECTRIC /OCD
• 1 certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00 -
in1'onnatton is correct.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COW 13 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP IOwr 500,000 BTU)SEE FEE SCH. MECHANICAL loZ
(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 a 'nil said City in consequ ace f the
granli 8 o his permit MECH.CONT. LIC.N0. MECH
OTAL X 2'.I'�? •'sYrn O /a
,a_ fiT YA
Sig re AP lican ontractar et �3. s,e,'Lu'"w '.uY�' I
OFFICE COPY