2975 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUIL I 6
((OJECT DENTI FICAT1(A PER ER \
BDhLOING APPLICATION & PERMIT
_ _ 2975
aaOREss 10 oo P ppE Vl�w C. ,
K M BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S�n'� "'10 PLAN CHECK VALIDATION
xx_NAME RR S QTY. ELECTRIC PERMIT FEE
S P.A PH-N,011
No�CU PL"(•Z'j7NO ��C„ OUTLETS-SWITCHES-RECEP 5.00/1.00
NAMEAME INL
� 'LIC.NO, q(j3 LIGHTING FIXTURES 5.00/1.00
AooAesC;Kk ac. 'r✓C y'V A✓f APPLIANCES-RESIDENTIAL 4.00
u. V /AE PHONE' - l ~ PANELS 5-00 DATE OF APPLICATION
ARCHITECT I SIGNS 6.00 PLAN CHECILFEE P.C.NO.
OR ��
ENGINEER
uc,No. SIGNS TRANS. 3.00
ARCD OR ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
zIP EMP.METER OR POLE INS. 15.00
APPLILas y
ADORES, /2x AF, c'✓e�VAI N✓t£ / MOTORS SEE FEE SCH.
�L(/✓.V ✓/.��/f (�'/! 9t/G J(_4 SERVICE CHANGE 10.00 r 'l// -f•3
o¢ z
RA'I'ION
(� (/
aiw
.02 LICENSEE CONTRACTORS EECI-A
a v I hereby affirm Ilett I am licensed under provisions of Chapter 9 ISSUANCE DATE
PH, Q y (Commencing with Section 7000)of Division 3.1 the Business and BLDG. I EI-ECT. 1 PLG. MECH.
H OProfessions Code, d a, I````'onse,is in full for pct ❑ O ❑
ion. License Class_ yU Lie.Number_ (O �
9 r Date CvmDaCt�,F.l
`a x BUILDING PERMIT
¢ ¢ ¢ u OWNER-BUILDER DECLARATION' INFORMATION
x n vHi I hereby affirm that 1 am exempt limit file Cold.actor l.icchsc MISC.- i'UVWTO ORD
g Busincs1 and Professions VALUATION $/FT.
La H .. 0J Law(..tile followin rcas'om(Sec.7031.5. PERMIT ISSUANCE 6.00 �. ../
Code:Any city or counly which requires a Permit to construct,alter,
2 2 Q p improve,demolish,ninepin any stood e,prior to its issuance,also ELEC.CONTR, LIG.N0. EC p0
o ¢ ¢quires the applicant for Stich permit to file a signed statement tlal N �2 TOTAO -/ PERMIT TO
a w$ he is licensed pursuant to the provisions of the Contractor's License FL EG
HiQLa..(Chapter 9(commencingwith Section7000)ofDivision3of the ,
i c Business and Professions Code)or that he is exempt therefrom and Y. PLUMBING PERMIT FEE
Mp the basis for the alleged exemption.Any violation of$ectiod 7031.5 STORIES TYPE CONSTR.
a by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
of not more than five hundred dollars(S500).):
❑ 1,as owner of the property,or my errhPIUyeCS with wages as BACK FLOW PROTECT. DEVICE 2.00 CCC.GROUP RES.UNITS
their sole compensation,will do the work,unit the Structure is not
'otonded or of(cHed for sale (Sec. 7044, Business and Pr.fcssinn, DRAINS-FLOOR,ROOF,AREA,COND. 4.00
CodeThe Contractor's License Law docs not apply to an owner o1'
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-
laments are not intended or offered for sale If,however,thebuilding GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or improvement is sold within one year of completion, the owner GAS-EASYSTEM-OVER 4 IEA.) 100 BUILDING USE
builder will have the burden of proving that h . . .
e did not build or im- RES IND CON PB Omer
prove for purpose ofsale). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑ ❑
Cl 1,as owner of the property,ad exclusively contracting wilh
licensed contract.,, to construct the proicct(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and professions Code:The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPR INKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contructorls)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
file Contractor's License•Law.
❑ lam exempt under Sec.-.B.&PC.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM . 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPEN'SATION DECLARATION WATER TREATING EQUIP. 4.00
1 herehy al(irm that I have a cert ih,,ty of.....,rent to,dhGinsure,
or a cctil'icum of W.rky'r ","Ilensaf ion honra ce,or a ccrtilicd ZONING ENG.SITE NO.
copy WcOCA- 17company-
Policy N'o.__company__ Q/.Y�IeIq_}7_SSV/Dda206
Q /❑�y/� L'etlif led COpy'If hereby(nrnlalted. FIRE SPRINK ENERGY T 24
z 2 Ap l¢erztiDgd co y is fl' ilvy.h the y iter a 'ot�di'vam. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
V N V N
Ir m CERTIFICATE OF EXEMPTION PROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.0 c.
DJ >_ CON I'ENSATION INSURANCE PLG.CONTR. LIG NO. PLG.
CL O (This section decd not be conmleted If the Permit is for one TOTAL Y ElN[] Y[:] N❑
D2 h....died dollars IS 100)or less.) ,
U O 1 certify that in the performance nt'the work for which this per. QTY. MECHANICAL PERMIT FEE ' FEE SUMMARY
LL F- ...if is issued,1.stall not enhploy any pcoon in any manners,as to
Ow becomvubjecno(lie Workers'Compensaf ion Laws of California. BUILDING
Date Applicant ALTER OR ADD TO MECH. 4.00
} N NOTICE TO APPLICANT: IL after making this Certificate ra Gx-
H Z emptlon,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions Or this permit shall be,cencd revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby alio that there is a construgion lending agency I'or EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which Illi,permit is issued(Sec. MICROFILM
3097,Civ.C.), HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC o�6 Qct
Lender's Address
I certify that l have mad this application and state that t e uh.ve VENTILATION FAN (SINGLE) 3.00
information is correct.I agree to comply with all city and counp• PLUMBING
R]Hances and state laws relating In building construction, and BOILER-COMPI3 H.P.or 100,000 B.T.U.) 4.00
hereby authori a representatives of this city to enter upon the BOILER-COMP 10ver 100,000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned Properly for inspection purposes
(We) agree to save, indeduti(y and keep handless the City of MISC.- REFER TO ORD.
Cupertino against whilifics,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in ah uec against said City in consequence of fire
grand •Hit or ! MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Sig ' re of Applicant Conlr for 4 f Date
OFFICE COPY