6298 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT lDENTIFICATION PERMIT NUMBERBUILDING APPLICATION & PERMIT
ADDRESS � 298
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OwNen's // _ --,_-� y�Y -y ELECTRIC PERMIT
y PLAN CHECK VALIDATION
DTy. .1^,': x '
�� L ONE ) a+ 4ww-n
CDNTRACTOR$
NAME . r��.fi%f/ OUTLETS-SWITCHES-RECEP 5.00/100
.c LIC.NO. LIGHTING FIXTURES 5.00/1.00 _
(:O NTRACTORs PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
OR
Llc.No, SIGNS TRANS. 3.00 '
ARCH.On ENG. PERMIT VALIDATION
ADDRESS SPECIALCIRCUIT 5.00
'ZIP rrEMP.METER OR POLE INS. 15.00
APPLI Nr'S MOTORS SEE FEE SCH.
A/DDRCA y
6 S 46A 093AX OS6 �r*,/� SERVICE CHANGE 10.00 v
0 0 0 LICENSI>D CONTRACTORS DIiCLARATION .(A U(1
a L,w Thereby affirm that I am licensed under provisions of Chapter 9 a l L ISS ANCE DATE
a (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH,
F N z Professions Code,and my license is in full farce and effect ❑ El ❑ El
o m- License Class Lie.Number
B w w Dam Contractor
a x s-�+ BUILDING11PERMIT
¢ ¢a OWNER-BUILDER DECLARATION M=R
o a u INFORMATION
X. 3.-I- I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
uoa Law for the followingreason. 7031.5,Businessand Professions VALUATIO E/FT.
y w PERMIT ISSUANCE - 6.00 l
f > 4 Code:Any city or County which structure p prior
rt to consuance,also
/L O
¢ Q a 0 improve,demolish,Or repair any ShIIUnR,pr Or IO 1[S ISanan W,aISD ELEC CONTE. LIC.NO. ELEC
u w m u used
the applicant for such permit to file a signed statement that TOTAL ' PERMIT TO
he is lice ed pursuant to the provisions of the Contractor's License ,r
rzi Law(Chapter 9(comme acing with Sect inn 7000)of l)ivision 3 of the x +y' �
4 o Business and Professions Code)or that he Is exempt therefrom and QTY)r},,h4+k' o,`1,"'PLUMBINGiPERM1T5-'y+✓b 'Vy).yR S,.FEE a B11
¢ r$ the basis for the alleged exemption.Any violation ofSection 7031 5 vry�„* , ` . r"=. '� sv. ' O >77gglq$ TYPE CONSTR.
by any applicant for a perrnitsuhjeets lire applicant to a civil penalty gLTER-DRAIN&VENT-WATER (EA.) 4-GD JU'1
of not more than five hundred dollars($500)):
❑ I,as owner of Die property,or my employees with wagesas BACK FLOW PROTECT.DEVICE 2.00C,ty C1ffl ""P RES.UNITS
their Sade compensation,will do the work,and the structure is not C&
""JP
or offered for sal.(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:'Tire Contmelor'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 So FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided(hat such improve-
mentsare not intended oroffered far anle.I L however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is Said within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or int
prove for purpose of sale.). INDUSTRIAL WASTE INTER. RES IND CON Pe Omer
❑ I,as owner of the properly,ant exclusively contracting with 20.00El El El El El
licensed contractors m construct the project(Sec.]044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contmclor's License Law does not apply
to as owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 '
contracts for uch projects with a cuntructor(sl licensed pursuant to
the Contnmtm-'s License Law. SEWER-SANITARY-STORM EA.200ft/8.00 ' TRACT NO. PARCEL NO.
u I am exempt under Sec. •,BAP.C.for this WATER HEATER W/VENT 4.00
or
Owner Dale WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS' OMPENSA1'ION DECLA RATIO WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate ofemsent to self-insure, - ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof I Sec.3800,Lab.C.1.
Policy No. Company
0' ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T-24
z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
0 ApplicantY 0 NY N�
F' m PERMIT ISSUANCE 6.00
CL - CIiRTI FICA MPHNEA17 M PION ION PROM WORKERS' FLOOD ZONE A.LU.C.
W � COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG,
0. N(_]0 17 his section need not be ecanpIctes] II the permit is for one TOTAL Y❑ N Y C] N
hundred dollars 1$100)or less.)
s
U I certify that in the performance of the work for which this per f at x 'dwF EE)SU MARY
LL I- nal Is Issued, I shall not employ any person In any manner so as to QTY;:'.t .. -" MECHANICAC�'P.ERMIT 't,5„?i'+s
U become subject to the Workers'Compensal ion Laws of California.
UJ Dam " Applicant ALTER OR ADD TO MECH. 4.00 BUILDING /�
} 0NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F. Z enptlion,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK /Sze
pro00
visions of the Labor Code, you must forthwith comply with FEE ry
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1Q0C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10DWC.F.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,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Leader's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lenders Address ELECTRIC
I certify that 1 have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
infornmtion is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating 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
above-mentioned properly for inspection purposes. BOILER-COMP (Over 100,000 BTU(SEE FEE SCH. MECHANICAL
(Wu) 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
--------------
granting of this permit. MECH.CONT. - LIC.NO. MECH.
�U�n/�t2rx4< re- 30�� TOTAL TOTAL
Signature of plicant/Contractor
OFFICE COPY