6772 -Ai"PLICANT TO FILL IN INFORMATION WITHINRED LINES —'USE B POINT PEN'ONLY • ,A
' BUIILDI NG PROJECT I DENTI FICA -' PE 7 NUMBER
A/��' a°,LG,NG /.^r, APPLICATION & PER '
Gv 1 BUILDING ELECTRICAL—PLUMBING—MECHANICAL .
ofw.rv�ERUs Yy 1„3 N PLAN CHECK VALIDATION
_AME Z PHONE Q V . °Y ,;4 4'ELECCTRIC3PERMIT
NACONTRACTORS OUTLETS-SWITCHES-RECEP 5.00/1.00
A 41 'LId.N LIGHTING FIXTURES '5.00/1.00
r-oNTRacro /� - (/ APPLIANCES--RESIDENTIAL 4.00 -
• ONE PANELS 5. 01_ DATE OF APPLICATION
ARCHITECT p SIGNS 6:00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC,NO, 'SIGNS TRANS. 3.00 '
ARCH.OR ENG. SPECIAL CIRCUIT S.OD PERMIT VALIDATION
DORi zP _ EMP.METER OR POLE INS. 15.00
APPIICANT'Su 1
ANGRESS /� K I - ,'Z MOTORS SEE FEE SCH.
jqgCLVtWxQC rCAL 6S SERVICE CHANGE 10.00 �/�
woo LICENSED CONT'RAC'TORS DECLARATION (/
¢ i w I hereby affirm that I am licensed under provisions of Chapter 9ISSUANCE DATE
at a a (commencing with Section 7000)of Division 3 of the Business and
BLDG. ELECT. PLG. MECH.
F H,z Professions Codes,am ''cense is in fullmb fort• f L
z o m — License ass.L:-_ _Ca Number
o w r' Date Contractor ` '
M x a El 11P
`�-AT . ,.BUILDIND PE MIT'
¢ a a OWNER-BUILDER DECLARATION a J1
w3 e.y I herebymffirm that'I am exempt from the Contractor's License MISC.- REFER TO ORD s :a�"INFORMATION
ca Law for the foil owi ng reason.(Sec.,7031.5,Business and ProfessionsPERMIT ISSUANCE - 6.00 ' VALUATION $/FT.
Code:Any city or county which requires permit to construct,alter,
¢ ¢¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. . ELEC. ' 't -
K
m LL' requires the applicant for such permit to file a signed statement that - TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractors License
i Law(Cha ter 9(commencin with Section 7000)ofDuision 3 ofthe `I-*°^""' e ' " a m' w;4`•, L
Business and Professions Code)or that the is exempt therefrom and nT;Ya•t m r 0 k..PLUMBING;P,ERMIT v s ;i's' aysFEENy
a'H o the basis for the alleged exemption.Any violation of Section 7031 5 i Vex'zar §fix, , q° t. STORIES TYPE CONSTR.
dim by any applicant for a permit subjects ore applicant to a civil penalty - - ALTER-DRAIN& VENT-WATER (EA.)of not more than live hundred dollars(S500)J: - -
❑`I,as owner of the property,Or my employees with wages ns BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP- RES.UNITS
their sole compensation,will do the work',and the structure is mot
intended or offered for sale(See x7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND.',4.00
Code:The Contractor's License Law does not apply to an owner of
properlywho build,or Improve,thereon,and who dues such work FIXTURES-.PER TRAP 4.0 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-'
Rents,are not intended or offered for sale.If,however,the building GAS-EA.SVSTEM-I INC.40UTLETS 4,00 ,
or 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 moving that he did not build or im-. O V RES IND- WN PB Omer
prove for purpose ol'saleJ: - INDUSTRIAL WASTE INTER. 20,00 - _
❑ 1,as owner of the property,am exclusively contracting with .E] O O � 13
licensed contractors to construel the project(Sec.7044,Business' LAWN SPRINKLERS.I 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 buildsorimproves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1,00 '
contracts for such projects with a contocnous)licensed pursuant to
tem Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/B.00 TRACT NO. PARCEL NO.
❑ ']a exempt under Sec. ,8.&P.C.for this ' WATER HEATER W/VENT - q,0
reason
Owner Date WATER SYSTEM 4,00 ACC.OATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION - WATER`TREATING EQUIP. 4.00 -
I hereby affirm that I have a certificate of comeat ro self-insure,
ora certificate of Workers'.Compensation Insurance,or,ocertified - °� ZONING ENG.SITE NO.
copy thereof(Sec.3500,Lab.C.). _
Policy No.—Company-
0
Company O ❑ Cettilied copy is hereby furnished. 11 FIRESPRINK ENERGY T-24
Z Z j� Certified y is filed with tm 'ity insppilion division. .-
O A'pplitin 7t, _ (T MISC.- REFER TO ORD. YE] N❑ 'Y ❑ No
� y CFBI1FICATE O°EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.C.
W COMPENSATION INSURANCE LG CONTR. ' I .rv0� PLG. ❑ ❑ ❑_ ❑
Z (Phis section need not be completed it the pennit,is for otic TOT0. V N V ry
hundred dollars($100)or less.
"V O I certify that in the performance oGthe work for which this per x a".�;,° F EE SUMMARY
LL F mil is issued,1 shall not employ any person in any mannerso as to QTY' MECHANICAL`'P.ERMIT :° FEEpi
U beeomu subject to the Workers'Compmhation Laws of Calif°rnm + - - -" `
Awa Date Applicant ALTER'OR ADD TO MECH. R 400 BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
2 emption,you should become subject to the Workers'Compensation APPLIANCE' 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply-with FEE
U such provisions or this permit shall be deemed revoked. t AIR HANDLING UNIT(TO 10MC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY' AIR HANDLING UNIT(OVER 1000011EM.) 5.00 SEISMIC FEE
1 hereby affirm that there is a construction lending aicncy for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work fur which this permit is issued(Sec. - MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4:00
Lender's Name HEATI NG UN IT(OV ER 100,000 B.T.U.)7.50"
Lender's Address - ELECTRIC
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00 ,fir
information is correct 1 agree to comply with all city and county PLUMBING - v '
I ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.or-100,000B.T.U.) 4.00 L/
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over,140,000BTU)SEEFEES6H. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless-the City at MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way ace rue.against said City in con quence of the - PERMIT ISSUANCE , 3.001 1
grant got this permit' '- _$C; MECH.CONT. LIC.NO. MECH.
fT E /. .dnrtl J TOTAL
�fSc�Sz YML TOT/1L
hignaturtiod Applicant/Contractor Daley . - a• k
,. OFFICE COPY