6724 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
/
'BUILDING APPLICATION & PERMIT
DOREss
/(j q J6724
4 BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S :'�' "ea Fy.J Ery ,2 ' xj ' `if'An. L ,y, PLAN CHECK VALIDATION
"AME DTV c'"ELECTRIC FERMI
+ FEE
w vl YYIff2 ' s .,,, ,� F Pa k
v HONE w1.1. ''. "5,
nAi"ueRACTORs UTLETS-SWITCHES-RECEP 5.00/1.00
}I K Cv/15��.(7 • uc.No. LIGHTING FIXTURES 5.00/1.00
CONTRACTOR 5 PPLIANCES-RESIDENTIAL 4.00
AonREss ^
ro5 / + flrt�r rPHDNE2J �V PANELS 5.00 DATE OF APPLICATION
ARRCHrtER SIGNS 500 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00
AonREss ENGSPECIAL CIRCUIT 5.00 PERMIT VALIDATION
xla FEMP.METER OR POLE INS. 5.00
AvaucANrs MOTORS S CH.
ADDRESS R/
SERVICE CHANGE 10,00
w a o LICENSED CONTRACTORS DECLARATION
a .u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y "' Icommrncing with Section 70601 of Division 3 of the Business and
<H BLDG. ELECT. PLG. MECH.
H w z Professions Code nil my license is in full force and effect. ❑ ❑ ❑ ❑
i z N o icen.Class _ Lic.Number��
o,A j Date /O- - Contractor Y SRN.Ci26 CD
¢ BE w¢ OWNER-BUILDER DECLARATION t
s,;u I hereby affirm that I am exempt from the Contractor's License
MISC.- REFER TO ORD 4 CIIT'
F LL O j Law for the following reason.Sec,703 t,5.Business and Professions PERMIT ISSUANCE _ VALUATION S/FT.
Code:Any city or county which requiresa Permit reconstruct,Site, 6'�
¢ ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
9 11.
recluires lite applicant for such permit to file a signed statement that TOTAL PERMIT TO
A w mhe is licensed pursuant to the provisions of the Contractor's License
'i
Law(Chapter 9(commcming with Section 7000)of Diison 3 ofthe �Nt•..'h r>r3s
5104 Nosiness and Puslessions Codec or Ilial he a exempt iherefrnm and QTY. SPWMQM PERMIT- + 'RE
¢ r$ the basis for the alleged exemption Any violation of5edion 7031.5 m-:�k1; r^.Y$.+�`r s+ J+'43y -a�L'" �+'`1:�L ^le 'P��' ''7N}�w. STORIES TYPE CONSTR.
n ; by any applicant I'or a permit subjects the applicant t o a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(5500).1:
❑ h 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 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
Iner"are not intended or o frcred for .Jr.rIf,however,the hudding GAS-EA.SYSTEM-1 INCAOUTLETS 4.00
or improvement is said within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 ButLOING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Offer
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 2000 ❑ ❑ ❑
❑ I,as owner of the Property,am exclusively contracting with .
licensed contractors to construct the project ISec. 7044.Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professiom Code'.The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contrudorisl licensed Pursuant to
the Contractor's License LawSEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owoer, Date WATER SYSTEM 4.00 ACC.GATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate Of consent to sel Ginsure' ZONING ENG.SITE NO.
or a cvfillicaae of Workers'Compensation Insurance,or a certified
copy thercof l Sec 3800,Lab C.).
/ Policy No. Company
O ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T 24
z ❑ Cemf py fled Ith the oily inspection division.
n TIP vcnl X,�12L2A-�i/1< MISC.- REFER TO ORD. r N� r N�
~ m ,((eif�'Q'N N`HO�Kr PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.c.
cc CE 1111t'ATE O'E%EMKFION FROM WORKERS'
W COh1PE:NSATION INSURANCE PLG.CONTR. ❑C.NO. PLG. v rv� r N�
Z ITh anon need not he completed it the permit is for on TOTAL
11 Andred dollars IS 1001 or less l _
U O I ert Yy (hat to the performance of the work for which this per' x'�' ,set, r� " rt«'v S ' a *iFEE SUMMARY ft:L'A}a
EL y�, MECHANICAt:PERMIT FEB.- 174;,,..,,, ts_-+?>.a,
IL 1- clot is issued, I shall not employ any person in any manner so as to
DTM' �y,y ( PAa
O W become subject to the Workers Compensation Laws of Caliform¢ BUIIDINGN
a Dale Applicant ALTER OR ADD TO MECH. 4.00
} m NOTICE 'f0 APPLICANTS. If,after making this Certificate of Ex-
FZ aoption.you should become subject to the Worker'Compensation APPLIANCE 4.00 PLAN CHECK
prov¢ions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1O000GF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MOC.F.M.) 5.00 SEISMIC FEE
I herchy affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.DO
(fie pectormance cf The work far which this permit ie issued(Sec. MICROFILM
3097-Civ.C.l. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,0008.T.U.)7.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
infnrnmtion is correct. I agree to comply with all city and county BOILER-COMP 13 H.P.Of 100,000 B.T.U.) 4.00 PLUMBING
ordinances and slate laws (elating To building construction, and
hereby authorise representatives of this city to enter upon the
above-mentioned property for inspection purposes. (OwnBOILER-COMP (Own 100,000 BTUI SEE FEE SCH. MECHANICAL
(We) agree to save, indmnnify and keep harmless rte City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
• ling 111 it. MECH.CONT. LIC.N0. MECH. •d:Z;'i,.•0t�(.` 'T-
oTAL :,?OTAL"K
gldinaturc-of ATBAicamiContractor Date
OFFICE COPY