6294 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
/BUILDING PROJECT I DENT]FICATION PERMIT NUMBER
BULInNG APPLICATION & PERMIT 6294
ADDRESS
`D 6o0 �1 i5v( vy cr. It+ BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
"AME T_ {Y ((� DTV. ELECTRIC PERMIT FEE
J-+r�/ I EIeSI L_ PHONE 4 It�1 44
CONTRACTOR'S ,OUTLETS-SWITCHES-RECEP 5.00/1.00
N e
Vlvf-p Poo 51erraiC.NO.Ilis o I ILIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
ADDRESS
p 2] CV16WCT SNE 253 9 PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER 1/O S- K
F 1 fCro_^ LIc.No. SIGNS TRANS. 3.00
ARCH.OR ENG. 5.00 PERMIT VALIDATION
ADURess - SPECIAL CIRCUIT
zlv EMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDREss
15VIC CT SERVICE CHANGE 10.00 r
o¢z
Foo LIC.IiNSED CON"I RACIORS DECLARATION
N
T o U I hereby affirm Ihul I am licensed under provisions of Chapmr 9 ISSUANCE DATE
N a w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
Hoz Professions Cade,am�(..f0�yy license is in full force'u Ify yy
ion- Liccnw Cha 7 _ (' =Lic.Numbe �.@ _M.(� 1 ❑ ❑ ❑
E, H w Dale_/�/.2$��9999'••• Cam"Cllr UOOt.Qfl_ESitI
¢ m¢¢ OWNER-BUILDER DECLARATION t rBU1LDING�,gPERMiT
¢ w }vhlf!IFORINATION.
REFER TO ORD -
A H 1 hereby at that 1 am exempt from the Contractor's License MISC._ VALUATION - $/FT.
r LL o j Law for the following reason.(Sec.]071.5.Nusinessand Professions PERMIT ISSUANCE 6.00
to Code:Any city or county which requires a permit to construct,alter,
¢¢Q 0 improve,demolish,or repair any structure,prior to its issuance,also FLED.CONTR. LIC.NO. ELEC.
D¢ requires the applicant for such permit to rile a signed statement that TOTAL PERMIT TO /M
A. w m LL he is licensed pursuant to the provisions of the Contractor's License C
Hzi lay.(Chapter 9(commencing with Seel ion 7000)ofUivisionJ of the - r`' EN �r2 /vF
a: Business and Professions Code)or that he isexempl therefrom and DTV. PLUMB ING PERMIT 'F.EE'..
$I D STORIE TYPE CONSTR.
¢ e the basis far the alleged exemption.Anyviolation ofSection?031.5
malty
d ;m by any applicant for a permit subjects the applicanttoacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
error more than five hundred dollars($500).):
D I.
as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensalion,will do the work,and the structure is nod
intended or offered for sill,(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:T'he Contractor's License Law dues nut apply loan owner of -
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SCLFT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
rents are not intended or offered far sale If,however,the building
r improvement is mild within one year of completion,the owner- GAS-EASYSTEM-OVER 4(EA.) 100 BUI LOING USE
provingbuilder will have the burden of proving that he did not build or im- . . RES IND CON PR Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ El 1:1 ❑ ❑
D I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-I INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
an I Prefessimis Code:The Contractor's License taw does nm apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to
SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO. PARCEL NO.
the Com"clor's Liccmn Law.
O Iron lender Ser..,B.&RC.for this WATER HEATER W/VENT 4.00
Dwncr _ _ Date . - WATER SYSTEM 4.00 ACC.DATE
ACC.FILE NO.
)R R. A'I'ION WATER TREATING EQUIP, 4.00
I herchy a him Thal 1 have a certificate of consent to sell-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compcnsmion Insurance,or a certified
copy there4f(Sec Wj$Qo I.ab.C.). -
olcy 31:ompany
1' �IJUVS1�Lk�.tiJX�mAI
Q 0 Cetil'ied copy is herchy luntisbed. cyp FIRE SPRINK ENERGY T-24
Z Z M. Certified w,y is filed with the bl ins esti n Division. MISC.- REFER TO ORD.
F O Applicant-(�JDOk.PI'I--moo b .b� Y❑ "❑ Y ❑ "❑
y CERT IF-ICA'11;OF txliM19 ION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD 2orvE 0.l.U.L.
LLl > COMI'ENSAT'ION INSURANCE PLG.CONTH. LIC.NO. PLG. YE] NE] Y� N❑
D• 0 ('Phis wctiou recd nor be completed if the flaunt is for one TOTAL
Z) Z hundred dollars f$100)or less.)
U O I certify that in the performance of the work for which this per, QTY MECHANICAL PERMIT FEE FEE SUMMARY,'..':•;"+y;'
UL H mit is issued,I shall not employ any person in any manner m. as to
O w fee mnc srlb)yyrg the Workcrs'Cl pc mtinp,��s�,,f I�"yrrnia. BUILDING
Dat"IMA-rdL Applicant-U=�=13KGN-IL9-Fa- ALTER OR ADD TO MECH. 4.00 U Rv
} to NOT'ICI.'l) APPLICANT: IL after making this CcHifhcare of Ex-
H Z_ cmption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you mut forthwith comply will, FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
- CONSTRUCTION LENDING AGENCY
AIRHANDLING UNIT(OVER 10p00C.F.M.) 5.00 SEISMIC FEE /0,Sn
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. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ.C.).
Lender's Name HEATING UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that I have read this application and SIaIhtheove VENTILATION FAN (SINGLE) 3.00
inf rmation is correct. I agree to conhply with alICl city ar and co.huntyPLUMBING
ordinances and stale laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hcrcby authorize nepresenrxlivcs of this city to corer upon the BOILER-COMP H.
100.000 BTU)SEE FEE SCH. MECHANICAL
above mentioned property for inspection purposes.
(We) agree to save, indenmfly and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in coawquenee of the PERMIT ISSUANCE 3.00
gtlmtingof this pemhil. MECH.CONT. LIC.NO. MECH. _
D� i7_ �/_ TOTAL TOTAL 4
Signatureol'Applicaintt//CContoiclor Date
OFFICE COPY