7059 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
aW LONGAPPLICATION & PERMIT n 0
ADDRESS - r
77j.4 /Pd1311V41z-7AL V✓'q-t BUILDING ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S q r,r e '_T Yu n;ffi y} i s" y,k,•hY- PLAN CHECK VALIDATION
"AME .7/t /9g OTV,�'Pv r� ELECTRIC'.P,ERMIT s,FEEI��
TayN GA RRUtt 9 YS-6e P d
ONE
caoRs
NAME UTLETS-SWITCHES-RECEP 5.00/1.00
NAME
sec.No. LIGHTING FIXTURES 5.00/1.00
ADDRs
AODRESS APPLIANCES-RESIDENTIAL 4.00
DHE55
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE - P.C.NO.
OR
ENGINEER
sec.NO. SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP FEMP.METER OR POLE INS. 15.00
APPLICANTS + MOTORS SEE FEE SAH.
ADDRESS
SERVICE CHANGE 10.00
w D o LICENSED CONTRACTORS DECLARATION O
u y w I heechy afl'um that 1 am licensed under provisions of ChepIW 9 ISSUANCE DATE z (commencing with Section 7000)of Division 3 of the Business and
¢ g BLDG. ELECT. PLG. MECH.
F w- Professions Code,and my license is N lull force and eNbcl. ❑ ❑ ❑ ❑
Z O a- hiccnse Class - Lic.Number
Q z Dale Contractor
MIS f aBUILDINGfRMIT '
¢ ¢ ¢ OWNER-BUILDER DECLARATION
A o a u r I' INF-ORMATION
w ; y 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD --
VALUATION -$/FT.
H .. o ar Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00 '
Code:Any city or county which requires a permit to construct,alter,
2 ¢ ¢ FO improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. - LIC.NO.- ELEC.
O ¢ requires the applicant for such permit to file a signerl stammenl that TOTAL
n.W m°' hPERMIT TO
e is licensed pursuant to the provisions ol'the Contractor's License ,
i Law(Chapter 9(commencing with Section 7000)ofl)ivision 3 of the - k
io Business and Professions Code)or that he is exempt II,vmfrnm'and UTV: r:r a '.P.LUMBING`'PERMIT' -
ac I-m the basis for lire alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a3 _ by any applicant for a permit subjects the applicant to a civil penally gLTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(8500).):
❑ I,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 Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code`.The Contractor's License Law docs not apply to an owner of
_ property wire builds or improves Brenton,and who do"such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that suchimprove-
mentsarenetintendedoroffereAforsale.l f,however,thehoilding GAS-EA.SYSTEM-11 NC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.( 1.00 BUILDING USE
builder will have the burden of proving that lie did not build or im-
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 20.00 RES IND ' CON PB Omer
❑ I,as owner of the property,am exclusively contracting with El El El C1 ❑
licensed contractors to construct the proiecl(Sec. 7044,Business LAWN SPRINKLERS,1 INC 5 V.8. 5.00 ASSESSORS PARCEL NO.
and Professions Codm'I'he Contractor's License Law does oll apply "
to an owner of propeity who huilds or improves thereon,and who. LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts fur such
projects with a conlraetods)licensed pursuant to
the Contractor;License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VgNAw 4.00
reason
Owner- Daley WATER SYSTEM ✓ 4.00 ACC.OATE ACC.FILE NO.
WORK ERS'COMPIINSATIDN DECLARATION WATER TREATING EQ IPI I�UJ 4.00 '
I hereby affirm thm I have a eSri ifierte of consent to self-insure, ZONING ENG.SITE N0.
or a certilicale of Workers'Compensation Insurance,of a certified p
copy BhereFLISec.3800,Lab.C.). •{ 01 ❑
Policy Nn. Company
O ❑ Cenilied copy is hereby furnished. az"
ZZ ❑ Certified copy is Filed with the oily inspection division. r / FIRE SPRINK ENERGY T-24
O Applicant MISC.- REFER TO ORD. Y[] N[_ ' Y ❑ N
y CERTIFICATE OF FXEMPLION 17ROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.e:
LU > COMPENSATION INSURANCE. PLG,CONTR, LIC,NO, PLG. (J
d 0 (This section need not be completed if the permit is for one TOTAL YO N❑ Y F] N�
Z hundred dOIIa,s(S I00)or hv,,) -.-s,�,v
U O I certify that in the performance of the work for which this per QT.W. -. MECHANICAL PERMIT FEE +'`REEF SUMH1ARVk 3- '}'$._
LL t- mit is issued.I shall net employ any person in any manner so as to
Ow become subject to the Workers'Compensation Laws of California. , BUILDING
y Date Applicant ALTER OR ADD TO MECH. 4.00
} N NOTICE '1'O APPLICANT: If,after making this Certificate of Ex-
F Z eruption,you should bacome subject to the Workers'Compensation APPLIANCE 4.00 ,PLAN CHECK
provisions of ore Labor Code, you mm
roust forthwith comply with FEE
U such provisions or this permit shall he deemed revoked, AIR HANDLING UNIT(TO 10XOC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY ._ AIR HANDLING UNIT(OVER-10=CF.M,) 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,CDC.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
'I certify that I have read this application and state that ore aboveVENTILATION FAN (SINGLE) loo
. information is correct. I egive 1.comply with all city and.county PLUMBING /0 .�
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or.100,000 B.T.U.) 4.00
hereby authorise representatives of this city to enter upon the BOILER-COMP Over 100,000 BTUI SEE FEE SAN. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs.and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence of the
grantingofthis'permit. .. MECH.CONT. - UC.NO. MECH.
TOTAL TOTAL' '
_*nature of Applicant/Contractor to
OFFICECOPY