6382 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
•K BU LD1 NG PROJECT I DENTI FICATI ON PERMIT NUMBER
AD,Lp,NG APPLICATION & PERMIT ^ ^
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An RE19 De BUILDING - ELECTRICAL-PLUMBING-MECHANICAL b G
NaMEgs `t . µ "f- PLAN CHECK VALIDATION
/LL/ AROCCD 7d . 87 DTV :off- ELECTRIC PERMITa lab f z FE&
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CONTRACTORS - OUTLETS'SWITCHES-RECEP 5.00/1.00
Ua NO.Ze-7/Z/ LIGHTING FIXTURES 5.00/1.00
CONTRACTOR 308 a9�Gb CT APPLIANCES-RESIDENTIAL 4,00
/LP/171 SRL. 9>03SPXONE 9
-;7,77e I PANELS 6.00 DATE OF APPLICATION
A.CmThCT SIGNS 6.00 PLANCHECK FEE P,C.NO.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
nooe ess ENG' SPECIAL CIRCUIT 5.00PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
gPPucANTs
ODREss MOTORS SEE FEE SCH.
`7_5V,35_SERVICE CHANGE 10.00 / �Y
w
Do LICENSED CON'1'RACfORS DECLARATION
SC
u u N I hereby atfirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w a w Icommencing with Section 7000)of Division 3 of the Businessand BLD ELECT. PLG. MECH.
H N Z Professions Code,and 1I99y license is in full role a feet. ❑ ❑ ❑
Z o m - License Claas_�!�Lic.Number Z
o N r w Dale T_/�-��7 Con Hactor O_�_�
hu la :P RMIT P
¢_ a w a OWNER-BUILDER DECI.ARATION K f+_ ,- `;y1NFGRMATIGN-'�v;
r MISC.- REFER TO ORD
x ;A I hereby affirm that I am exempt from the Contractor's License
LL o a Law for the following reason.(Sec.7031.5.Businessand Professions VALUATION SIFT.
_ PERMIT ISSUANCE 6.00 e9�J
Code:Any City orcounty which requires a permit to construct,alter,
R2 ¢ improve,demolish,or repair any slreclurc,prior m its issuance,also ELEC.CONTR. LIC.NO. ELEC. (/Oe
¢ wD ¢ requires the applicant for inch permit to file a signed Statement that TOTAL PERMIT TO
Is he Is licensed pursuant to the provisions of the Contractor's License
z ¢
Law(Chapter 9(commencing with Section 70001o'Division 3 olthe +S, 1 v 'f3` 4 Y
Business and Professions Code)or that he is exempt therefrom and QT V: PLUMBING PERMIT ,xiw. fpr
¢ r o Ole hulls for the alleged exemption.Any violation f Sem un 7031 5PS r'i I+b it ; 4 {xg$'fv=.`'�"y s,�,T^y, M i, rS'.'ity� TORIES TYPE CONSTR.
a- ; m by any applicant far a permit subjects the applicant lox civil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
of not more than five hundred dollars f 55001.):
❑ 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 sale (Sea 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:'rhe Contractor's License Law does not apply to an owner of
properly 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 that such improve- GAS-EA.SYSTEM-11NC.40UTLETS 4.00
Rents are not intended or offered for sale.If,lmweveq the budding
or improvement is sold 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 im. AES IND CON PB Omer
prove for 1.as weer of sale.1. INDUSTRIAL WASTE INTER. 20.00 0 0 0 0 0
O d as owner of the property,he exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Pron owner III Cole:The honbuil,1or's License Law does not apply
to contracts
owner of property who builds t r improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
the(
is for such projects with a contraeoO sl licensed pursuant to
the COn Donor's License Law. SEWER-SANITARY-STORM EA.200(t/8.00 TRACT No. PARCEL No.
❑ lam exempt undar Sec. .B.&PC.for this WATER HEATER W/VENT 4.00
Ow2on
r Date - WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WURKFi RS'cOMP1iNSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby atirm that I have a ceriv ican,of consent to self-insure, ZONING ENG.SITE NO.
s�.• or a certificate of Workers'Compensation Insurance,or a certified
cup,thC,C f 3 0, b
Policy No.�S rl
❑ Cetllll '0"6 hereby furnishe FIRESPRINK ENERGY T"24
Z 2 f.en J d y is int mspec i on.
O ApTi.;,gt 1e_( yi � MISC.- REFER TO ORD, Y ❑ N Y ❑ NE]
Fy PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.uc.
LU C T'IPICATIS 0171 ATIO FINS FROM WORKERS'
lL COM net be coo INSURANCE PLG.CONTR. LIC.rv0. PLG. Y F] NC] Y❑ N
� Z ITI, section need not be completed if the permit is for TOTAL
funded dollars 15 100)or IrVxJ ,�N f 7q„+vc+5'�d.94+vk'Tti'."1 pa,. R,w.
V O I rlify that in the performance of the work for which this per,
p• ,a MECHANICAIc PERMIT � FEH$UhVII�A.. w,._S•..-
U. F mit is ssued I Shall but employ any person in any manner so as fo _ �E}tiL•�`S,. -rypr.•p� 0 -
11,11,
O w become subject to the Workers Compensation Laws of California -
pale A li ant BUILDING
CL PPC' ALTER OR ADD TO MECH. 4.00
} w NOTICE TO APPLICANT: IL after making this Workers'
Compensation
se.Ex-
2 em vision you should become subject to the Workers Compensation qpP LIANCE 4.00 PLAN CHECKsuch
t tuns of me Libor Cade, you dee d revoke comply with FEE /-4t-
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10p00C.F.M) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 5.00 SEISMIC FEE ,J(p
1 hereby affirm that there is a Construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the 3097 performance
C.jnce of the work for which this permit is issued 15ec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
• Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50
ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP love,100.0000TUI SEE FEE SCH. MECHANICAL
above R entioned 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
may in any way accrue against said City in consequence of the
g I gofmlS er 1�. MECH.CONT. LIC.NO- MECH.
TOTAL
nature of Applicant/Contractor Data
OFFICE COPY