6241 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER BUILDING
f���J APPLICATION & PERMIT 6241
'
AD0RE ,g $, - BUILDING—ELECTRICAL—PLUMBING—MECHANICAL Q
w 'A a': PLAN CHECK VALIDATION
NAMERs � QTY ' "' ELECTRICIPERMITff1 FEE
. asa63 1/ ,
i// �Q'L rHONE f 'h.,
roNERncroRs/f UTLETS-SWITCHES-RECEP - 5.00/1.00
PLS/ uc No7`I�Y� LIGHTING FIXTURES 5.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
'
X"
'3�/(� 5.00 DATE OF APPLICATION
OR
CT ��- SIGNS B QQ PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENGSPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00 c
ADDRESS - MOTORS a SEE FEE SCH. f
SERVICECHANGE 10.00
0 0 o LICENSED CON TRACTORS DECLARATION
a i w I hereby affirm that I am licensed under provisions of Chapter 9 Oar G ISSUANCE DATE
w a: (commencing with Section 7000)of Division 3 of the Businessantl BLDG. ELECT. PLG. MECH.
y z I'rofessluns Code,and m license is in full foJc}-'nn e 1 L rs ❑ ❑ ❑
Z,oL�Lic.Numher (
o w L w Uate 01/ S Contractor/ ,a-
a m ��' '+BUILDING PERMIT '
¢ ¢ se a OWNER-BUILDER DECLARATION : P-.-
'x c-°'r I hemby'affom that I am exempt from the Contractors License MISQ— EFER TO ORD - a:LUL IORMQ;T,ION
F u m j, Law for the following reason.(Sec.7031.5,Business and Professions •. PERMIT ISSUANCE- 6.00 VALUATION SIFT.
Cade:Any city or county which requires a permit toconstruct,alter,
¢arr ¢Q
improve,demolish,or repair an structure,prior EL 'CNf��TR LIC.NO. ELEC _
p p y + n its Issuance,also �Y ///��
O LL requires the applicant li+r such permit In hie a signed statement that ! TOTAL PERMIT TO
u w$ be Is licensed pursuant to the provisions of the Contractor's License
F i Law(Chapter 9(commencing with Section 7000)of Division 3ofthe - '.-
io Itusmess and Professions Code)or that he is exempt therefrom and OTKW, L 9 '= z 'PLUMBING PERMIT FEET
¢I-$ the basis lar the alleged exemption Any violation of Section 7031.5 ,?" - 4 STORIES TYPE CONSTR.
a3 - by any applicant for a permit subjects the applicant to a civil penalty .ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars 155001.1:
❑ 1,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 Prol'essiops DRAINS-FLOOR,ROOF,AREA,GOND. 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 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such improve-
mentsarenotintendedorofferedforsale.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) 1QQ BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CDN PB Omer
prove for purpose ofsale.). - INDUSTRIALWASTE INTER. 20,00
Cl. 1,as owner of the properly,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to constract the project(Sea 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5,00 ASSESSORS PARCEL NO.
and Prefessions Code:The Contractors License Law does nut apply
to an owner of property who holds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a conlmctor(s)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sea ,B.&P.C.for this WATER HEATER W/VENT 4.00
mason
Owner Dale WATER SYSTEM 4.00 ACC.OATE ACC,FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 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)Sco.3800,Lub.C.). �—�- •7�-f__-
Policy No, Company
O ❑ C led copy Is hereby furnished.
yam}' yI C q�p�g�pee tdivision.
_i� FIRE SPR INK ENERGY T-�<
Zp crti Apvlicunl_�YC`1 �-- MISC,- - REFER TO ORD. - Y ❑ N❑ vNO
I-- rn PERMIT ISSUANCE 6A0
CER1'IFICATF;OF EXEMPTION FROM WORKERS' FLOOD zo NE A,LOU,C.
LU > COMPENSATION INSURANCE PLC.CONTR. LIC.NO. pl-G, `
Z (This section need not be completed if the permit is for one TOTAL v❑ N❑ Y❑ N[_hundred AolWrs($100)or less.) - -
U O 1 certify that in the performance of the work for which this p'r. OTV.' ± ' MECHANICAL VERMIT'. ':`FEE'' FEE SUMIa1ARVA
LL H mit Is Issued,1 shall not employ any person in any manners as to - - n'/"• ---
O W become subject to the Workers.Compensation Laws of California.
CL Uare Applicant - ALTER OR ADD TO MECH. 4.00 BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of Fi:-
F Z enlption,you should become subject to the Workers Compensation APPLIANCE 4.00 PLAN CHECK
In visions of ilia Labor Codi, you trust forthwith comply with
U such provision or this Permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F,M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10ACC.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,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name H EATING UNIT(OVER 100,000 B.T.U.)7.50 -v
Lender's Address - ELECTRIC S
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLET 3.00
information is correct. I agree to Comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and 130ILER-DDMP(3H.P.Or100,000B.T.U.) 4.00
hereby authorise representatives of this city es enter upon the BOILER-COMP (Over,100000 BTU)SEE FEE SCH. MECHANICAL
hereby aRtioned property forinsp ofth i purposes.
(We) agree m save, indemnify and harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgm t ors
Cupertino expenses which CONST.TAX
may in any way rue agai s Ily,in consequence f the PERMIT ISSUANCE 3.00
granting of Ih II. MECH.CONT. LIC.NO. MECH.
„� TOTAL 4"TOTAL "
pplicant/Contractor ate -
,OFFICE COPY