5521 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES ' USE BALL POINT PEN ONLY
, PERMIT NUMBER
BU I LDING PROJECT IDENTIFICATION APPLICATION &,PERMIT -
BUILDING ' 5 5 2 1
AD �esQs e BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
•��+ AIN %C> la }v�y" - " PLAN CHECK VALIDATION
Osoxi e ls` 51 .f8
NA E - GTV. .ECECTRIC P-
ERMIT(
IP 5n�,Eii is
PHO
CONTRACTORS UTLET5-SWITCHES-RECEP 5.00/1.00
NAM[
t�(•/\ps-.I'� LIC.NO :Ug LIGHTING FIXTURES' 5.00I7.00
Z1�
GONTRACTOR's 1,00 PPLIANCES-RESIDENTIAL 4.00
AGGRESS 1 _
tag �� PUONE� 1` PANELS - 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.06 PLAN CHECK FEE P.C.NO.
OR
ENGINEER SIGNS TRANS. 3.00
ARCH.OR ENG. , 5.66 PERMIT VALIDATION
ADDRESSSPECIALCIRCUIT
ZIP EMP.METER OR POLE INS. . 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
woo LICENSEDCONIRACT'ORS DECLARATION A or rT '
Ie u sHa I hereby affirm Thal I am licensed under provisions of Chapter') ISSUANCE DATE
w 4 y (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F o z Professions Code,�Ilnd�my�ici is in full fu a nit effect. ❑ ❑
o y- License l.r Lic.Number Z
o w t w Date_ G!i_CG�Contracmr=_,A�`L.Q
' BUILDING PERMIT
a ¢w u OWNER-GUILDER DECLARATION - ^ ', INFORMATION
K 3 s- N I hereby affirm that 1 ant exempt from the Contractor's License MISC.- REFER TO ORD
VALUATION Q $/FT.
w u_ort Law for the following reason.(Sec.703 1.5,Business and Professions PERMIT ISSUANCE 6.00
t - w Code:Any city orcounty which requires a Permit to construct,alter,
Be QQ0 improve, nT repair any at RlCture,prior l0 Its ISounce,also ELEC.CONT". LIC.NO. ELEC.'
BI o¢ requires the applicant for such permit to Isle a signed statement that TOTAL PERMIT O
n w m u he is licensed pursuant to the provisiooI lire Contractors License
F z i
Law(Chapter 9(commencinns gwlth Section 7000)of Division Sof thea
k;,.7^y,'•n, �,a,4 `) SFl�rt25
a Business and Professions Code)or that lie is exempt therefrom and .k-'PLUMBING,PERMIT h'`i.. ba" 1,FEE
o the basis I'or the alleged exemption.Any violation of Section 7031.5 * /".' HE TYPE CONSTR.
a m
by any applicant for a permit subjects the applicant loacivil PenaltyER-DRAIN&VENT-WATER (EA.) 4.00 r$ N
of not more than five hundred dollars($500).): - -
❑ I,as owner of the property,or my employcci wi0i wages asK FLOW PROTECT.DEVICE 2.00 P RES.UNITS,
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and ProfessionsINS-FLOOR,ROOF,AREA,COND. 4.00
Code.Thu Contractors License Law docs not apply to an owner of
property who builds or improves thereon,and who does such workTURES-PER TRAP 4.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- -EA.SYSTEM-1INC.4 OUTLETS 4.00
mems are not intended or offered I'or sale.If,however,the building
or improvement is sold within one year of con piction,the owner- S-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Otnm
prove for purpose of sale.). USTRIAL WASTE INTER. 20.60
❑ d conwncr of this construct
he exclusively contracting wish
' licensed contractors to construct the project(Sec.7044,BusinessN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to un owner of prvPon,who builds or improves thereon,..it whoN SPRINKLERS-OVER 5(EA.). 1.00
contracts.lox such projects with a couracto"s)licensed panuant toER-SANITARY-STORM EA.200ft/5.00 iRACT.NO. PARCEL NO.
the Contractors License Law.
❑ I am exempt under Sec. ,B.&P.C.for thisTER HEATER W/VENT 4.00 -
reason
Owner Date WATER SYSTEM 4.00 ACC.OATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have acertificate of consent to self-insure. - ZONING ENG.SITE NO. '
or a certificate of Workeri Compi,nation Insurance,or a certified
cop,Ihcreof(Scc.3800,Lab.C.) ���,�
Policy No. Companyshed . -
Q ❑ Certified copy is hereby furni . O` -i FIRESPRINK ENERGYT24
Z Z CurkifUd copy is filed with the.1''Iy -,rte Inspection division. MISC.- REFER TO ORD. y E] No y E) N[]
O hp ent
(r Lo CERTIFICAT'EOF EXEMPTION PROM WORKERS'
^ PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
Lu >_ '
COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. ❑ ❑
d 0ForTOTAL Y N V N
(This section need not be completed If the permit is one
Z) 2 hundred dollars IS 100)or less.) *. .FEEISUMNIARY ';,;
L) O I certify that in the performance of the work for which this per- DTV• ^. ", C MECHANICAL P,ERMITa- `
F mil is issued,I sliall not employ any person in any manner so as to g , • I " / rn
Ow become subject to the Workers'Compensalion Laws of California. BUILDING S(p tl "
Date Applicant ALTER OR ADD TO MECH. 4.00
} y NOTICE: '1'O APPLICANT: IL after making this Certificate of Ex- - q,60 PLAN CHECK
F 2 eniption,you should become subject to the Workers'Compensation APPLIANCE .
provisions of the Labor Code, you must forthwith comply with AIR HANDLING UNIT(TO 10,060 C.F.M) 3.00 FEE'
O sutIt provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10PWC.F.M.) 5.00 SEISMICFEE - Sa
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for winch this penis is issued(Sec: MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT IOVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that l havethis application and state that theabove VENTILATION FAN (SINGLE) 3.00
read PLUMBING
information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
ordinances and slate laws relating,to building construction, and
hereby authonoC representatives of this city to enter.upon the BOILER-COMP (Over 100,000BTUI SEEFEESCH, MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, casts and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in Consequence of the
ling o 's ermll. MECHof o .CONT, LIC.NO...
TOTAL `L' `vTOTtAL"''« S7
igna ure 1 c r - Date
OFFICE COPY