7048 • " APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT 1 DENTI FICATIONPERMIT NUMBER
1 BUILDING APPLICATION & PERMIT
T� PoOwDrvRER's 6 CHANICAL
OGBUILDING-ELECTRICAL-PLUMBING-ME7048-
PLAN
OTVPLAN CHECK VALIDATION
NAM E
,SoutH 6A �/J.11^K.TItL1/ Y DTV \` 'Y' * 3ELECTRIG-PERMIT'
1 3y-o t:1L� R .
PHONE
NANME ACTon's OUTLETS SWITCHES-RECEP 5.00/1.00
R(3STON P/Mt.`A)C4 UC.rvQ*.76}660 LIGHTING FIXTURES 5.00/1.00 ,
P-ONTRACTOR'S-
ADDRESS II .0wau Z13 w� /� APPLIANCES RESIDENTIAL 4.00
/ ta.$ S.twrO aAlt4 PH..E VZ-1_Z7 PANELS '5.00 DATE OF APPLICATION
ARRCHITECT SIGNS S.00 PLAN CHECK FEE P.C.NO.
` ENGINEER
• LIC.No. SIGNS TRANS. 3.00
AaRC
DDH.
OR ENG. SPECIALCIRCUIT 5.00 - PERMIT VALIDATION
SS
zIP ITEMP.METER OR POLE INS. 15.00
APPLICANT'S
a00RE55 MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
w DLICENSED CONTRACTORS DECLARATION _ /✓/O "
a v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
m et
¢ (commencing with Section 7000)of Division 3 of the Business and
- BLDG. ELECT. PLG. MECH.
F.�z Professions Code,and my license is in full farceyyluQQ��[[jje�ct.
oz W License Class Lic.Number_�2(271r(vCL El ❑ El
Contractora_Cr�J��-�
- c x T U " 'BIJILDING"PERMIT a}
¢ 0 w u OWNIiR-0BUILDER DECLARATION r '
w u m 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD INFORMATION ,
FUO .) Law for the following reason.(Sec.7031.5,Ba,messand Professions PERMIT.ISSUANCE - t. . 600 VALUATION, S/FT.
v, Code:Any city or county which requires a permit to const ruct,alter, .
_
¢ ¢ 2O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
a a O_IZ requires the applicant for such permit to file a signed statement that TOTAL PERMITTO
K
m" he is licensed pursuant to the provisions of the Contractor's License '
' r "i
Law(Chapter 9fLmnnhencingwith Section 7000)ofDivision3ofthe \ -
io Business and Professions Code)or that he is exempt therefrom and QTY. `n#'` PLUMB IN GIP E RM IT,
IS gy m the basis for the alleged exemption.Any violation of Section 7031.6 'R STORIES TYPE CONSTR.
a3 _ by any applicant for a permit subjects the applicant macivilpenalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars($500).):
❑ 1,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,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SQ.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such inhpmvo-
�. mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4,00
or improvement is sold within one year of Completion,the owner-
builder will have the burden of proving that he did not build or am. GAS-EA.SYSTEM-OVER 4 (EA.) . 1.00 BUILDING USE
prove for purpose of pale.). - RES IND CON PB Ofluo
❑ 1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 20.00 0 ❑ 0 ❑ 0
licensed contractors m construct the project tSec.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 MAI . 1.00
contracts for such projects with it contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.2001t/5.00 I TRACT NO. PARCEL NO.
❑ I ani exempt under Sec. ;B.&P.C.for this
reason WATER HEATER WIVENTm.+J,9bJ*yr,,, 4.00
owner Date WATER SYSTEM - 4,00 ACC.DATE ACC.FILE NO.
WORK E RS'COMPENSATION DI'.CLARA'I'ION WATER TREATING EQUIP, 0). 1,4.00
I hereby affirm that I have a certificate of consent to self-insure,- �'.'r)t ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified _
copy thercofi Sec.3800,Lab.C.L ,F n•
Policy No. Company _ V 'r _
O. ❑ C liked copy is hereby furnished. FIRE SPRINK ENERGY T-24
z z erthfied copy is filed with the city inspection division.
O i\ plicum-QRC59Qil-{1/.Li'1Je11S7 1 MISC.- REFER TO ORD. Y[. NE] Y [3 NF]
~'w PERMIT ISSUANCE 6.00
� - CERFIFICA'1'Ii OF i:xFmrfION PROM WORKIiRS' FLOOD ZONE A.L.U.C.
EL W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO, PLG
2hundred
(This vccllon need not be completed If the penmt is for one - TOTAL `- Y[] NEIY 0 N
h ndred dollars(S 100)or less.)
(,) O 1 certd' that in the performance of the work for which this h'+s ab e- n a '" +" s M "'-'
y p p DTV,..- + . '•,MECHANICAL\1P,ERMIT h; tY *,FEE''. - FEE¢6UMARY
LL H mil is issued,I shall not employ any person In any manner so as to >, «
O w become subject to the Workers'Compensation Laws of California.
D, Uate Applicant ALTER OR ADD TO MECH. 4.00 - BUILDING
} 0 NOTICE TO APPLICANT: If,after making this Certificate of fix-
F ? emption,you should become subject to the Workers'Compensation APPLIANCE 1 4,00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with. FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10ACC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 5.00 - SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(W ITH'DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ.. • HEATING UNIT(TO 100,000 B.T.U.) 4.00 .
Lender's Name HEATING UNIT(OVER 100,000 B.T.U0.50
Lender's Address ELECTRIC
1 certify that I have read this application and state(list the above VENTILATION FAN (SINGLE) 3.00 - G
mr.unation is correct. I agree to comply with all city and county PLUMBING 7a
ordinances and state laws relating to,building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authonze representat," of this city to enter upon the BOILER-COMP IOVB!100,000 BTU)SEE FEE SCH. MECHANICAL
above-Ineationed properly 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 COnS<gnenCe of the
granting of this pe'In.L - MECH.CONT. LIC.NO.
/�3��� TOTAL TOTAL
S' lure of Applicant/Contractor Date
OFFICE COPY