6243 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDINGADDRESS APPLICATION & PERMIT . 6243
^ A ^
ADDRESS '2 / G L�3
7 33 L//✓LYOtc� BUILDING
NAMER a. r ta'+& It. t"s`A ,x"'.. a y= '. #Mq' t$ t'#` ` x •% ' PLAN CHECK VALIDATION
QTYY s" T#r C,EL'ECTR IC PERMIT , FEE' -
v1Q7,q G.6 5Y�/I
CONTRACTORS
NAME r OUTLETS-SWITCHES-RECEP 5.00/1.00
G� S UO.� i✓ mc.No ,30'-/ LIGHTING FIXTURES 5.00/1.00
ADORE TOnTi PPLIANCES-RESIDENTIAL 4.00
ADORE p` / e]
2 A//fr 0- PRONE (^�/{ PANELS 5.00 DATE OF APPLICATION
AARRCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENc. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
Arvrs - • MOTORS SEE FEE SCH.
ADDRESS
I Q
.29 11/VAI
e TO wo-V SERVICE CHANGE 10.00 Ill
Fo0 o LICENSED CON'I'k ACTORS DECLARATION J® -. _
< i u I hereby affirm that I am licensed under provisions of Chapter'I 3-F � ISSUANCE DATE
y 4 vt (commencing with Section 7000)of Division 3 of the Business and �. LD LECT. PLG. MECH.
r N z Professions Code n I y license is in full force a effect.
z O w - LiClass_ -i 4 Lic.Number O-
4 _COntracvsr yd t
OWNER-BUILDER DECLARATION v" 4 r�"I GING PE M
-
X;LL w I hereby affirm that I am exempt from m
the Contclor MISC. REFER TO ORD
s License
U.
O 4 Law for the following reason.(Sec.7031.5,Business and Professions
VALUATION $/FT.
H - PERMIT ISSUANCE 6.00
Cod¢Any mol or county whiny structure poor to itssisuance,also
,
¢ ¢O improve,demolish,or repair any structure,prior t0 its issuance,also ELEC.CONTR. LIC.N0. ELEC.
o LL requires the applicant for such permit to lite a signed smtement that TOTAL
w$m he is licensed pursuant 10 the provisions of the Cont rector's License TO
I.S.(Chirac r 9(commencing with Section 7000)of Division 3 of tlie
-
4 Business and Processions Code)or that he esexempt therefrom and QTY.", ="IPLUMBINGsPEWIT t'}smo "ayFNEE{x`•.
Be r'o the basis for the alleged exemption Any violation ofSeclnm7031S F STORIES V CONSTR.
,a3 � by auy,xpplicaut for a permit subjects the applicant a civil penalty x"
ofnotmorethanrtvehundreddollars(5500).1: - ALTER-DRAIN& VENT-WATER (EA.) 4.00 ,
❑ I;as owner of the property,or my employees with wages as BACKFLOW PROTECT. DEVICE 2.00 OCC.GROUP Res.UNITS
their sole compensation,will do the work,and the structure is not
intended m oll'ered for sale (Sec. 7044, Business and Pmfessicns DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's Llc rxe Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SG.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such improv
tee-
mentsarenorintendedoroffed far sale.I L however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
rr iln Provement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.). 1.00 B
builder will have the burden of proving that he did not build or an. WILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER2000 ES IND CDN RB Other
[1w
I,as on . .
owner of do,property,am exclusively contracting with CO
licensed contractors to construct the Project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Cade:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such Projects with o contmera"O licensed pursuant to
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 I TRACTNO. PARCEL NO.
0lam exempt under Sec. ,lL&ItC,for(his
reason WATER HEATER W/VENT 4.00
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORK E RS'COM PENSAT ION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate 0f consent to self-insure,
or a certificate of Workers'Compensation Insurance,or u cert art ZONING ENG.SITE NO,
copy thereof(Sec.3800,Late.CA ) "
Policy No. Compan
O ❑ Cert ' Py is hereby lurnis eh d. FIRE SPRINK ENERGY RY4
Z Z rlifieGJI file wit the ' inspection division.
O Applicun4a1; �i„� MISC.- REFER TO ORD. Y 0 N� Y [] NCJ
� N CERT'IFICATE 01:IAEMPI'ION PROM kKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE. PLG.CONTR. LIC.NO. PLG.
EL o crin, action need not he completed if the permit is for one OTAL Y NY N�
-� Z hundred dol Ia.IS 100)or less.) -
U O 1 certify that iii the performance of the workfor which this per UTY'. MECHANICAL PERMIT , FEE FEE'SUMMARY•`'a'a 4�
U_ H not is issued,I shall not employ any person In any manner so as to
O w bcc nec suhjcat to the Workcnv'Compnnsntlon Lows of Ciihfontla.
Dam Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} y NOTICE 'r0 APPLICANT: If,after making this Certificateof I?x-
? 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 he decmcd revoked. AIR HANDLING UNIT(TO 10)000C.F.M.) 3,00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 1000C.RM.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Cis,C.). - HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATI NG UN IT ER 100,000 B.T.U:17.50
Lender's Address ELECTRIC
I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
iN'0nnalion is correct.I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorire representatives ec this city to enter upon the BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
herebymentiorite represeerty tLrinsp of
tion purports.' -
(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 iny way accrue aguins said City in consequence of the -
gmutin n aIit tetnl1. I MECH.CONT. LIC.NO, MECH.
TOTAL 'TOTAL
C':
lgnatureof Applicant/ ontracto Date
- OFFICE COPY