5953 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION 'r `' PERMIT NUMBER
BUILDING APPLICATION & PERMIT '5953
FOORESS '
h � BUILDING-ELECTRICAL-PLUMBING'-MECHANICAL
•T ry E , na PLAN CHECK VALIDATION
7(J� DTV. ELECTRIC PERMIT FEE
If (tea,/ PHONErpa ,�"e! �'^'' I•.'l d
-saE oRs OUTLETS-SWITCH ES-AECEP 5.00/100
LIGHTING FIXTURES' - 5.00/1.00 '
r.ONTRA 's _ APPLIANCES-RESIDENT IAL - 4.00
ADORES- S'-I C p
PRON iQ eA PANELS. 5.00 DATE OF APPLICATION
P RITEOr . SIGNS - B PLAN CHECK FEE .C.NO.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
AODRE--ENG. SPECIAL CIRDLIIT - 5.00 PERMIT VALIDATION
!'iIv EMP.METER OR POLE INS. 15.00
ASMOTORS SEE FEE SCH. '
ADDRESS
'
SERVICE CHANGE,. 10.00 p-
F02,
o
OO LICENSED CON TRACTORS DECLARATION ���
a v I hereby affirm that I am licensed under provisions of Chapter 9
'r' (commencing with Section 7000)of Division 3 of the Business and ISSUANCE DATE -
i Professions Coda�,.(;Is.�d..ymy�liken is in full fO -a of rel BLDG. ELECT. PLG. MECH.
z o y- Date-.LicCnV {'Iu`s�I- / Lm Num,
9 y F
Date- _ Con(rutto '
Be 2 w¢ OWNER-BUILDER DITLARA' I _BUILDINO�,PERMIdT
°a ° , MISC. REFER TOORD 'D '.$'INFORMATION;'j,,, ; .
X ; N I hereby affirm that I am exempt from the ontractor s License
Law for the following reason.(Sec.7031.5;Businessmad I'rufcssions PERMIT ISSUANCE 6 00 VALUATION-T$/FT.
five Code:Anycity Orcounty whlchrequiresupermitloconsirlict,altcq - S2_'149�J
a:Q.O improve,demolish,or repair any structure,prior to its issuance,also ELEC.DDNTR. LIQ N0. -ELEC.
w
O , requires the applicant for such permit to file a signed statement that TOTAL PEPMIT TO
d w w he is licensed pursuant to life provisions of the Contractor's License '
r z a Low lChoPtcr9(commencingwittiSLetion7000)of Division3ofthe - I y C 1@0o� ES
4 o Business and Professions Code)or that he is exempt therefrom and DTV: `„PLUMBING:PERMIT, KEEL
Ce the basis forthe alleged exemption.Any violation of5ection 7031.5 n STORIES TYPE CON-TR.
Le 3 .- by any applicant for a permit subjects the applicant to a civil penalty
of not more than live hundred dollars 050M.) ALTER-DRAIN&VENT-WATER MAJ 4.00
❑ I,as bwnrr of the property,or my employees with wages us BACK FLOW PROTECT. DEVICE 2,00 OCC.GROUP REs.�
their sole compensation,will do the work,and the structure is not uNrts
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 2L �✓ LJ
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and W to.dOcasuell work FIXTURES-PER TRAP 4.00 SO.FT.FLOORAREA TOTALACREAGE
himself or through his own employees.provided Ihat such improve- -
nfentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner. GAS,-.EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE r
miller will have the burden of proving that he did not build or an-
Proveto,purposenfsule.)' INDUSTRIAL WASTE INTER.' 20.00 -RES IND CON PB Ofbar$,
O I,as owner of the property,am exclusively contracting with �-
licensed contractors to construct Dm project(Sec.7044,Business LAWN SPRINKLERS-7 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Codu:The Contractor's License Law docs not apply
to an owner of property who huilds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts forsuch projects with a contmctos/s)licensed pursuant to -.
the Contmcmr's License Law. , SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ firm exempt under Sec.-,RAP.C.fm tlfis
leillor WATER HEATER W/VENT 4.00
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WO•RKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. , 4.00
I hetchy affirm Ihot I have u certificate of consent to self-insure, -
Or a certificate of WorkInsuranceo
COmpensatinn Insurance \I ZONING_ ENG.SITE NO.
/ copy thereof lSec.3500,Lab.C. . .
Play No. Compan _ _
O ❑ Certified copy is herby
efu fished. FIRE SPRINK ENERGY T 24
Z Z ❑ Cedifie Xry,Is Bled i f the city inspection division. ,
�. Applicant- MISC.- REFER TO ORD. v N� Y'Q ' N�
~ wa, -
� - CIiRTI EIC ATI: Z,BIN ROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.UL.
'W �_ COMPli' ' ION INSUkANCIi PLG.CONTR. LIC.NO. PLG,
C'Z (This section need not be completed if file permit is for one TOTAL Y N� Y NE)
L) Z his
dollars($100)or less.)
U O I certify that In the performance of the work for which this per DIV• '�;2' e rc FEE SUMINAR�Vgv
LL U nut Is issued,I sloll net employ any person in any manner so as R' , t f •-M ECHANICAL.PERMIT-,r w. " ' at FEES
become subject to the Workers'Compensation Laws of California. . ,„
0 Do Date Applicant BUILDING
} N NO1PLICANT:'ICIi TO APIf,after making this Certificate of fix- ALTER OR.ADD TO MECH. 4.00
F ? emptio",you should become subject to the Workers'Compensation APPLIANCE „4.00 PLAN CHECK
provisions of file Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT ITO 10=1C.F.M.) 3.00
CONSTRUCTION LENDING ACENCY AIR HANDLING UNIT(OVER I0OOOC.F.M.) 5.00 SEISMIC FEE
1 hereby affirm that filer. is a construction lending agency far EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT ITO 100,000 B.T.U,) 4,00
Lender's Nome HEATING UNIT(OVER 100,000 B.T.U.P.50
Lender's Address ELECTRIC
I certify that i have read this application and slate 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-COMP 13 H.P.Or 100,000 B.T.U.) 4.00 -
hemby authorize representatives of this city to enter upon the BOILER-COMP(Over 10,000 BTUISEE FEESCH.
0MECHANICAL
I 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
me n a"
iy way accrue against said City in consequence of the
g. Ig of way
Ill MECH.CONT. LIC.NO. MECH. -
Signature of lice tI ontr or Date - TO AL anTOTAL4,': d =0
OFFICE COPY