6953 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BDIEDING APPLICATION & PERMIT 6953
ADDRESS,D � D BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
rl OwNE 'S PLAN CHECK VALIDATION
l4 "NAME 1 QTYELECTRIC PERMIT FEE
/C / 0 PRONE .
co"rRacroR's UTLETS-SWITCHES-RECEP 5.00/1,00
CONT
JL.K7 LIC.., LIGHTING FIXTURES 5.00/1.00
CONTRAcr Ws .( PPLIANCES-RESIDENTIAL 4.00
`-� ADDRESS /AA/ ��/1
3 (1tJ PRONE TQT de) PANELS 5.00 DATE OF APPLICATION
ARCHITECT $IGN$ 6A0 PLAN CHECK FEE P.C.NO.
OR
E NGINEEH
LIc,No, SIGNS TRANS. 3.00
ARCH.OR ENG, SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00
Ars
ADDRESS MOTORS SEE FEE SCH. s
ORESS
SERVICE CHANGE 10.00 _
o o LICENSED CON'I'RACfORS DECLARATION
a u wI hereby affirm that I am licensed under provlslulls of Chapter 9 1,^,f� n ISSUANCE DATE
N ¢a Icon.Penchi,with Section 7000)of Division 3 of the Business and I s / - BLDG. ELECT. PLG. MECH.
F m i Professions Code,and my license is in lull fo c• d f cy�. ,�l , ❑
Z O m,- License Cl s_ Lic.Number . LoJ El
O zm- IJalc_� /� Contmct
of Cupertino
Q w¢ OWNER-If UILDER DECLAR I N City BUILDING PERMIT
A D e. U MISC.- REFER TO ORD INFORMATION
wg r 1 hereby affirm III t 1 am exempt from the Contractors License
to Lnw for IIIc litlowing remun.lSec.7031.5,Businessand Professions VALUAT,q t '$/FT.
'PERMIT ISSUANCE 6.00 1 1 n'\I 1 1 1
L- y Cade:Any city or county which requires a permit to construct,alter.
a. M ¢ o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR, LIC.NO. ELEC
¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT/TOT
u w m w he is licensed pursuant to the provisions of tire Contractor's License C VDD ert)nn
Fir
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe N C� vVe, - oAeC,
Business and Profirssioms Court or that he is excn.pl therefrom and QTY. PLUMBING PERMIT FEE -7•c O
r c the basis for the alleged exemption.Any violation of5ection 7031.5 STORIES TYPE CONSTR.
w5m by any applicant titrupennit.whjects the:Ipplicunt toacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(4500).)':
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
then sole Compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code:'1'lie 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 TOTALACREAGE
himself or through his own employees.Provided that such improve-
menisarenotintendedoroffiemdforsale.IL however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,fire owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or int- RES IND CON PB Other
Pave for purpose of sale.). INDUSTR(ALWASTE INTER. 20,00
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ F] F] ❑
licemed contractors to construct file project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Profcssions Code:'I'lle 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 her such projects with it conlmctons)licensed pursuant to
the Contractors License Law. ' SEWER-SANITARY-STORM EA.200f1/8.00 TRACT NO. PARCEL NO.
r ❑ I am exempt under See ,B.&P.C.for this WATER HEATER WtVENT 4.00
mavcm
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKI:RS'COMPI:NSA1ION DECLARATION WATER TREATING EQUIP. 4.00
I hemby Orlon Boat I have a<ertilicale of cumunl to scl Ginsurc. ZONING ENG.SITE NO.
(k or a cen#CA
kers'Compensation Insurance,or a certified
V copy thc ,Lah.C-.1.
Palicy Nupany
Q ❑ Cecreby furnished. FIRE SPRINK ENERGYT 24❑ Cefiled with the-city inspection division. REFER TO ORD.OApplican MISC.- V❑ N❑ V ❑ N❑COF I?XEMP1'ION FROM WORKERS' PERMIT ISSUANCE 6.00PL000 ZONE A.L.U.C.
W 1'ISNSATION INSURANCE PLG.CONFER. LIC.NO. PLG.
(L O ('Phis Section need not he con..leted if lire pennit is for one TOTAL Y❑ N❑ v❑ N❑
D Z hundred do1lars(SI00)or less.)
U O 1 certify that in the perforn.ance of me work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
Il F- mil is issued,I shall not employ any person in any manner m as to
U become subject lo.the Worken''Compensittion Laws'uf California. p S7J
O w
fare-Applicant BUILDING 1ssp
I ALTER OR ADD TO MECH. 4.00
} m NO1'ICI:'fO APPLICANT: If,alter making this Certificate of lix-
Z nnption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK 0
provisions of the Wbor Code, you most forthwith comply with FEE Q 3
U such provisionsor this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=11F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00GEM.) 5.00 SEISMIC FEE �16�
I hereby affirm that there is a Construction lending agency lot EXHAUST HOOD (WITH DUCT) 2.00 t
the performance of lire work for which this Permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00 n
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 � 3
Lender's Address ELECTRIC
I certify that l have read this application and stale that file above VENTILATION FAN (SINGLE) 3.00
Rees correct m I agree comply with all city and county(RdiPLUMBING
information and hexa laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,0008.T.U.) 4.00
hcmby authorise r resentaI ives of this city to enter upon lire BOILER-COMP (Over I00,o00 BTUI SEE FEE SCH. MECHANICAL
Obove-mentioned o cr forinspeclion PurPosa.
(We) a e to '.dwnnify and keep harmless lire City of MISC.- REFER TO ORD.
Cuponin aim h ies,judgments, costs and expenses which CONST.TAX
Puy in afy�6w i', m against said City in c.me"un.ee of the PERMIT ISSUANCE 3.00
,anti g rfh P . MECH.CONT. LIC.NO. MECH.
TOTAL
TOTAL
Si roof ppliCanUContactor 'Date
OFFICE COPY