0656 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL. POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION I I
PERMIT NUMBER
BUILDING APPLICATION & PERMIT 0656
ADD/IRl:ss 4/g , fdfo BUILDING- ELECTRICAL-PLUMBING-MECHANICAL
OINNERR'5 ..� "sY F:'�`•''` . _'�--;' 1--,PS 11.- ' PLAN CHECK VALIDATION
NAME
AME6dat ,1.ELECTRIC PERMIT k_ - Os5!, a FEE',
III
CONTRACTOR S
N^ 96110
' UTLETS-SWITCHES-RECEP 5.00/1.00
LW NO 96 LIGHTING FIXTURES 5.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADDRESS �^
5'/b PHONE PANELS 5.00 DATE OFAPPLICATION
ARRCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER se3.00
LIC No. SIGNS TRANS.
ARCH,OSN END' SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
APPLICANTS
AMOTORS SEE FEE SCH.
DOR ES
( Q / SERVICE CHANGE 10.00
0 0 o LICENSED CONTRACTORS DECLARATION
<u u I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
N<( commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
y i Professions Co an m license is in full for f
0 In- License CIlss Lit.Number `, _ ❑ ❑ ❑
ve i Dale-G..goZ 8fContrector
i Y 2 6 7 d O -8 If BUILDING PERMITq•..".�'
e C W a OWNER-BUILDER DECLARATION �� �:r;,INFORMATION'ft, '•''s(
uDAD MISC.- REFER TO ORD
;w a I hereby affirm that I am exempt from the Contractor's License VALUATION S/FT.
sa0J Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,alter,
Ny ELEC.CONTR. LIC.NO.
e a p improve,demolish,or repair any structure,prior to its issuance,also ELEC.
r 0 LL
It the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w m he is licensed pursuant to the provisions of the Contractor's License . . [l
Hi >
Law(Chapter 9(Commencing with5ection 7000)afDivirmn 3 ofthe
- • _ "i >-11111 ru -( 'H --
14 c Business and Profeumns Code)or that he is exempt therefrom and OTY 1,i,-,- F•. �I�P.�,LUMBING PERMIjTIy' `:+± ,'• {_ FEE,
a $ the basis for the alleged exemption.Any violation of Section 7031 5 _,. 1,i.E '! n "'iM.0 `�'°1?2111 S y sbA-.E .',„ STORIESIP TYPE CONSTR.
d
R by any applicant for a permit subjects the applicant ton civilpenalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(5500).):
❑ 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 to(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 SD.FT.FLOOR AREA TOTAL ACREAGE
himself re of rote his own employees.provided that such imProvo-
menti are through
his on employees,provided
ed that such
building GAS•EA.SVSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did nut build or IT. IGAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
RES IND CON PB One,
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ L as owner of the properly,he exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors odto The
nthe project(Sec.7044.Business LAWN SPRINKLERS-1 INC5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The who
Contractor's License Law does not apply
to tr owner of property who builds tr improves rased uand who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractarls)licensed Pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200f[/6.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for this WATER HEAtFffrV,0yE6TPERT1N0 4.00
reason
Date Owner WATER SYSTEM 4.00 ALL.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREA U A.1981 4.00
1 hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a rertified
copy th f
Policy ( Cdldsalf/ _ ,
O ❑ Certifie copy is Bereb famished. FIRE SPRINK ENERGY T24
Z Z ❑ Car( CO y s 0 wit the city inspection division. Y N Y N
0 Applicant �_ MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
� y CERTIFICATEOf EX PTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.C.
LU 7 COMPE T ON INSURANCE PLG.CONTR. LIC.NO, L.G.PY❑ N❑ Y C] N❑
CL Z (This section need not be completed if the permit is for one TOTAL
hundred dollars(S 100)or less.) .. I;r
U O I certify that in the performance of the work for which this per. UTV w - MECHANICAL_PERMIT FE
I ", FEE SUMMARY`S
IL - mit is issued,I shall not employ any person in any manner so as to a.• ti s
O W become subject to the Workers'Compensation Laws of California Q. Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING 11916D
} 0 NOTICE TO APPLICANT: If,after making this Certificate of Ex'
I.- Z emption,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 deemed revoked. AIR HANDLING UNIT(TO 10 00C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10A)OC.flNt) 5.00 SEISMIC FEE 5�
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which his permit is issued(Sec. MICROFILM
3097,Civ.C.). /� �� �' HEATING UNIT ITO 100,000 B.T.U.) 4.00
Lender's Name (-4LeIM ean Zia, HEATING UNIT(OVER 100,000 B.T.U.17.50
Lecertify
iAddrcss � I ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN(SINGLE) 3.00
information is o
correct.I agree to comply with all city and county PLUMBING
ordinances and state laws relatingo to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTUI SEE FEE SCH. 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 CONST.TAX
a
min any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
g in8 this P it.
MECH.CONT. LIC.ND. MECH, en .�G,�-
TOTAL TOTAL�; w 20,Sign ure ofA ph nt(Contractor ate
OFFICE COPY