6111 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBERAPPLICATION & PERMIT
BOILmx
AOIREss BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 6111
i P5 ,;r %
PLAN CHECK VALIDATION ,
i xANE CITV. . ELECTRIC PERMIT
P vxoNPrJJ ,• ` ,xl...0 I. :"fy Ms2, to
YCOHT1ACTO 5
NA . UTLETS-SWITCHES-RECEP 5.00/1.00
1 Llc.xo /S 5 1 LIGHTING FIXTURES 5.00/1.00
Ds
ADDRESS PPLIANCES-RESIDENTIAL 4.00
RESS
{ :•PHONE, ) - PANELS 5.00 DATE OF APPLICATION
ARCHITECT, - - PLAN CHECK FEE P.C.NO.
OR . SIGNS ,6.00
ENGINEER
Llc.xo. SIGNS TRANS. 3.00
ADDRESS ENa. SPECIALCIRCUIT "5.00 PERMIT VALIDATION
ZIP ITEMP.METER OR POLE INS. „ 15.00
APPLI - MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
, 09 LICENSED CONTRACTORS DECLARATION 1
v w 1 hereby'affirm that I am licensed under provisiousnf Clmpter9 u' kID ISSUANCE DATE
y G m (ca..... Acing with Section 7000)of Division 3 of the Rosiness and BLDG. ELECT. PLG. MECH.
N z Professions Conu is in full forge and ell'ec1�.�o y
Z o t: - [)are c.Gl'ss Lic.NumMr`'6f} 2 � Jai A ' SEPRE�.; 4❑ ❑ ❑
O a, r w 'Ua[c Uf Contractor _/4C��'
¢ 2 w OWNER-BUILDER DECLARATION La+,,-.`4 BUILDINGSPyERMIT -
O d MISC.- REFER TO ORD _F,ORMATION
R ; LL 1 hereby affirm that I am exempt from tire Contractor's License
law for the following reasmn.(Sec.7071.5,Rosiness and Professions ATION $/FT.
H _ g PERMIT ISSUANCE 6.00
m� Code:Any city fol or county which(Sec, 031. ,Business and reconstruct, ns
ta ¢ p insprove,demolish,or repair tiny structure,prior to its issuance,also ELEC.CONTR, LIC.NO. ELEC.
D ¢ quires(be applicant for such permit to file a signed statement that TOTAL
a rew m w he is licensed pursuant to the provisions(it the Contractor's License - q�PERMIT T
H i
Law(Chapter 9(commencingw'ith Section 7000)o'Division 3 ofthe - s-: �/�twl-
$ i o Business and Professions Code)or that he Is exempt therefrom and CITY. PLUMBING PERMIT; ... FEE,
SEH the basis for the alleged exemption Any violation of Secllon 7031.5 - > ' d"':' TORIES TYPE CONSTR.
d3 � by any applicant for a permit subjects the applicant to a civil penalty gLTER-DRAIN&VENT-WATER (EA.) 4.00Kt-
ot not more than five hundred dollars($5001):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OIck�cI.GKaI�oa�u.�P� � RES.UNITS
Their sole compensation,will do the work,and the structure is not y �yY O��
intended or offered for sale(Sac. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 I f e
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• hinnclf or through his own employees,provided that such improve.
melts are not intended or offered for sale.IL however,the building GAS-EA.SVSTEM-l1NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-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 Omar
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20,00
❑ as owner of the property,am exclusively contracting wish
lirenlicensedd contractors to construct tire 13 F-1
O. O project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code The 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 for such projects with a contractors)licensed pursuant to
the C'ontractor's License Law. - SEWER-SANITARY-STORM EA.200ft/8.00 TRACT No. PARCEL No.
❑ I am exempt under SL,.-,BAVC.for Bn,
reason WATER HEATER W/VENT 4.00
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate id consent to self-insure, -
or a certificate of Workers'Ccmpe��II t o Insurenee, r u cert eJ ZONING ENG.SITE NO.
cupy thereof l See.3800,Lab.C.).S,9 e �
Policy No. Company `!2? w-c;
0 ❑ Certified copy ishereby furnisheATI .T- FIRE SPRINK ENERGY TZ4
Z Z y"CertiQul/copy is Elyd�witb fhtytisy Espeulion division. ❑
O Applicant n MISC.- REFER TO ORD. v N v N
E ( ,,� PERMIT ISSUANCE 6.00
CC - CER'I'IPICAT>OP INEh1PTl0� PROM WORKI>R$' FLOOD ZONE A.L.u.C.
LU COMPENSATION INSURANCE. PLG.CONTR. LIC.NO. PLG.
L Z (Phis section need not be complete,] if the permit is for mu - TOTAL Y❑ N❑ V ❑ N❑
U O hundred dollars IS 100)or less.) y,
I certify that in the performance of the work for which tltis per. CITY MECHANICAL PERMIT FEE '"FE EjSUMMv'ARV"eT#`&'..
LL H ..tit is issued, I shall not employ any person in any mnnncr so as to
O L) become subject to the Workers'Compensation Laws of California. /
u Date - Applicant - ALTER OR ADD TO MECH. 4.00 BUILDING
} to NOTICE '1'0 APPLICANT'. If,after making this Certificate of E..
H Z cmplion,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shell be deemed revoked. AIR HANDLING UNIT(TO 1Q000CF.M.) 3.00
CONSTRUC'f10N LENDING AGENCY 'AIR HANDLING UNIT(OVER 10,000CEM.) 5.00 SEISMIC FEE
I hereby affirm that there•is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
,lie performance of the work for which this permit is issued(Sec. - MICROFILM
3097,Civ.C.L 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 the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-CON?(3 H.P.Or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 1GOLDOO BTUI SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree to save, indemnify and keepharmless 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
gmnUngOfthh peryk/ MECH.CONT, LIC.NO. MECH.
,"_rr "' ��10_;�'_ of TOTAL TOTALi"x ; . 'S7 �
!am
SIgnature ofn1¢an[Conl etor Date a^a
OFFICECOPV -