18924 (3) APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY
BUI LDI NO PROJECT I DENTI FICATION PERMIT NUMBER
oGILGt APPLICATION & PERMIT
°R 18924
BUILDING
OWNER'S PLAN CHECK VALIDATION
NAME���(' QTY. ELECTRIC,PERMIT FEE
MQ .7�L�' C PRGNE ' - •-
CONTRA91OiORS
10.00/1.00NAme -SWITCHES-RECEP,C / I LIGHTING FIXTURES
10.00/1.00
Roo EssioRs Gam" V1PT><-0 '' ,p APPLIANCES-RESIDENTIAL 4.00
L3C/ RfL/ ('HON§ PANELS 10.00 - GATE OF APPLICATION
ARCHITECT , PLAN CHECK FEE P.C.NO,
OR PANELS (OVER 200 AMP) 20.00 .. -_.
ENGINEER
uc,NO. SIGNS TRANS. 3.00
ADDRESS ENG.. SPECIAL CIRCUIT 5.00PERMIT vnu DATION
EMP.METER OR POLE,INS, -20.00
APPLICANTS
MOTORS SEE FEE SCH.
A
SERVICE CHANGE 20:00
0 2LICENSED CON'FRACFORS DECLARATION. -
rt PA
cwr. I hereby affr. that I an licensed under provisions of Chapter 9 VVV ISSUANCE DATE
N rt m (commencing with Section 7000)of Division 3 of the Business and •• BLDG. ELECT. G. EC .
F y z Professions Code,and my license Is in t 1 f u1 1 ,
zOw License lass_ _ Lie Nliinber _ _�w�+.�j� •r,- . r.. El ED
o y t w Date-1S-_�'1,.-�-Contra-.-. 1n1A+�/�"^ J
Q y ErJ
¢ 4 OWNER-13611-DER DECLARATION BUILDING PERMIT
E Q an U . 1 _ INFORMATION
X 3 ¢m 1 hereby affirm that I am exempt from the Contractors License: MISC.— EFER TO
of Law for the followingreasun.fSec.7031.5,Businessaudl'rotessicns' ,pERMIT.ISSUANCE VALUATION $/FT.
Code:Any city or county which re9uires a permit to construct,alien
caR Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC,CONTR. LIG N0. ELEG.
0 a requires the applicant for such ReDdif to life a signer)statement that TOTAL
n w m UL he is licensed pursuant to the provisions of Ole Contractors License PERMIT TO_
r i Lnw(Chopler 9lcommencing with Section 7000GfDivision3oftlm v
5 i o Business and Profeaslons Code)or that he is exempt there(rnt,and DTV. - - PLUMBING PERMIT FEE �
' sT
¢ 1-S the basis for Ilia alleged exemption.Any violation of Section 7031.$ STORIES TYPE CONSTR.
by any applicant fora permit subjects licam macivil penally ALTER-DRAIN -WATER (EA) 500
of not more than five hundred dollars(55001.1S5000 . " ,
: ,
❑ 1,as owner of the property.or my employees with wages as BACK FLOW PROTECT.DEVICE$ -3s9G '� OCC.GROUP RES.UNITS
their Sole compen Sulion,will do the work,anA the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,
Code:The Contractor's License Law dues not apply to an owner of
property who builds Or Iproves thereon,and who does such work FIXTURES-PER TRAP
mCr SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided Ihat such improve- ,.•� '�
meals are not intended or offered for sale.ll;however,the budding GAS-EA.SYSTEM-11NC.4OUT(�.
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.1 ,'2.00
builder will have the burden oLproving that Ile did not build or ilii- - BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES IND CON PB One,
C1 1,as owner of the Properly,ant exclusively cmatmcfn,with . .
❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS'- 1 INC 5 V.B. '6,00 ASSESSORS PARCEL NO.
e and Professions Code:The Contractor's License Law does not apply
a 10 ail owner of.propery who builds or impmvas thereon,'undwho LAWN SPRINKLERS,-OV ER .) 1001
contracts for such projects with a conlractor(s)licensed pursuant to SEWER-SANITARY-STOR EA.200tt
the Contractors License Law. - TRACT NO. PARCEL NO.
❑ 1 and exempt under Sea B.&P.C.tbrthis - WATER HEATER W/VENT
reason
Owner Uma WATER SYSTEM 5.00 ACC,DATE ACC.FILE NO,
WORK ERS'CONPENSATION DRCLARA'I ION WATER TREATING EQUIP. 5.00 - -
I hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers Compensation Insurance,or a certilied' ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company - -
0 ❑ CerllOed copy is hereby furnished.
FIRE'SPRINK -ENERGY TQ4
Z Z Fplicant copy Is filed wn11 the cit mspemion Aivision.
.. F-g` Applicant— ._L�AJY �� MISC.- - REF TO ORD. Y❑ N❑16 1 Y ❑ , N❑
to
LU CIiR"FI FICATE OF SAI IO TIFROM WORKERS' PERMIT ISSUANCE FLOOD ZONE - A.L.u.C.
W > COMPIiNSAI'ION INSURANCE PLG.CONTR. L PLGCL .
0 0 `U Ins section need not be completed if IIIc permit is for ❑
one I TOTAL Y - N❑ O
'Y'❑ N
hundred dollars(S 100)or less.)
. 0 0 1 cartity that in the performance of the work for which this'per- OTV MECHANICAL PERMIT FEE FEE SUMMARY -
LL F mit is issued,1 shall not employ any person in any mmmncr so as to -
Ow become subject to lite Workers'Compensation Laws of California.
Dam Applicant BUILDING
NOTICE 'I'O AI'I'LICAN'F: If,alter making this Certificate of Ex- ALTER OR ADD TO MECH., 5.00
f" ? emption,you should become subject In the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
Prov isions of life Lids... Code, you most r..thwith comply with FEE I -
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000GF.M.) 4.00 -
CONSTRUCTIONLENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
The performance of clic work far which this permit is issued(Sec. MICROFILM •�� -
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U'.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address - ELECTRIC
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE), 4.00
information is correct. I agree to comply with all city and countyPLUMBING
'•' ordinances and state laws relating to building construction, and' BOILER-COMPI3 H.P.or-000,000 B.T.U.) 6.00 -
hereby authorize representatives of this city to emer upnn•th°' BOILER-COMP (Over'100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned rpperty for inspection purposes.
(We) agree to save, Indemnify and keepharmless the City of MISC. v REFER TO ORD.
Cupertino against liabilities,judgments, costs Dad expenses which PERMIT ISSUANCE 10.00 CONST.TAX .�
io in any way accom against said City in coluequenec of the
ranling of this permit. ." MECH.CONT. LIG N0. MECH. vL/
-� TOTAL TOTAL IO f
grature 01 APPIIL'ao Contractor IJale -
OFFIQE COPY