4380 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I T;FICATION PERMITNUMBER
aUILDIND APPLICATI . & PERMIT /� 3 p 0
wooDEa 9 9 a -r-
OWNERS s `h 0
• UILDING-ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S `vr. J'I ' 'r•' Y +# �, (Y.yTp;, PLAN CHECK VALIDATION
"AME DTV: < ELECTRIC PERMIT r," PEE'a
m ' ,e°
cory DAc s1s UTLETS-SWITCHES-RECEP 5.00/1.00
LIC NO. LIGHTING FIXTURES 5.00/1.00
cONTRACTOR's APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 5.00 DATE OF APPLICATION
ARCRITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEE
n bBILIc.No. SIGNS TRANS. 3.00
ADDR.SD
c. jl�w SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
DODEMP.
:21+ METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
AooDEss
3 axaGaur J SERV ICE CHANGE 10.00 ?1114W o o LICENSED CONTRACTORS DECLARATION
rc uu I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
aa i (commencing with Section 7000)of Division 3 of the Business and SLOG. ELECT. PLG. MECH.
C Z Professions Code,and my license is in full force and effect ❑ ❑
o 0 v`3 W License Class Lie.Number '1
H W J Date Contractor
;BUILDING PERMITrf.?'!-:..la
¢ a w 4 OWNER-BUILDER DECLARATION y,.
0 g, I - ATION ,
X 0 A n I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
3 V UA ION 5/FT.
H w o a Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
Code:Any city c r county which requiresa permit to construct,alter.
2 ¢ ¢ 2 improve,demolish,or repair any structure,prior l0 its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- e Cftaw
u requires the applicant for such permit to file a signed statement that TOTAL PER10VTO
w $ he is licensed pursuant to the provisions of the Contractor's License
yI9„' /
i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
r 4 Business and Professions Code)or that he is exempt therefrom and DT'V: PLUMBING PERMIT 4 + t , .('FE t' •v/
¢ $ the basis for the alleged exemption.Any violation of Section 7031.5 ^ '' - 4*_' .✓!:eq' I "{'.`.`*'T.i '°t µ:h`L5b 'S RIE TYPE CONBTR
d ; by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars I g500).):
❑ 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• n intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00 /J- vZ
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.DO SO,-/FTp FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
n / /
.ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00 / V,-d
m-improvemet is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.1 1,00 BUILDING USE
builder will have the burden of proving that he did not build or im. RES IND CON PB Omar
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the properly,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sea 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO33
and Professions Code:The Contractor's License Law does not apply e2 /� 0 J
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00 3 6
contracts for such projects with a contractorts)licensed pursuant to
the Contractor's License Law. SEWER-SANITARYSTORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec. A.&P.C.tot this WATER HEATER W/VENT 4.00
reason
�(
Data WATER SYSTEM4.00 ACC.DATE ACC.FILE NO.
CE
WO s'CO PENSA tSA���RA TIOP-' WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO,
copy thereof(sec.3800,Lab C.). N,9,v
Policy No. Company
❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T�24
Z Z ❑ Certified copy is fled with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y ❑ N❑ Y ❑ No
y CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C,
Lu COMPENSATION INSURANCE PLG.CONTR. LIC NO. PLG
C Y❑ N❑ v [3 N❑
(This section need not be completed if the permit is for one TOTAL
D Z hundred dollars(SI00)or Itss.l ti)✓" r.9e .,IT a•x" r }T,p �t- �y.'t,1fm a r"f, U yya�iw'; „�«'(, b^ ,.
U O I certify that in the performance Of the work for which this per CTY' ai -+' eMECHANICAL PERMITU'-4• ,; FEES' FEE BUMMARV7 :
LL F- mi[is issued.I shall not employ any person in any manner so as to t•a°f, meq, a fiI y r :q'�. 9,P
U become subject to the Workers'Compensation Laws of California. �• `' 'c -
y Date ApplicantBUILDING
ALTER OR ADD TO MECH. 4,00
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex'
F.. 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 10ACDC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10AMC.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
S3097,Civ C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00 Lender's Nameerh0.P}ASer n, - '-
Lender's HEATING UNIT(OVER 100,000 B.T.U.17.50 ELECTRIC
I certify that) ab5r0l Ahhppli.'at• nj 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-OOMPQ H.P.Or 100,000 B.T.U.) 4.00
.hereby authorize representatives of this city to enter upon the BOILER-COMP IOWIr 100,000 BTU)BEE 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
may any way accrue inst said City in consequence of the PERMIT ISSUANCE 3.00
g of th ermi. MECH.CONT. LIC.NO. MECH. '•j`moi,^ w;' V
TOTAL 'V'•7„ C(�"``r
�-/ #-TOTA �T- Vy
Ignalureol'A s t/Contin Date
�/16o/I.L Q4e?_'CU'Oyj.(/j, OFFICE COPY