6812 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT /� /�
ADDRE,: 6812 V 1 2
ew .� BUILDING ELECTRICAL PLUMBING-MECHANICAL rVIU I G
OWNERS � ,�TC,P-f`� a % }•I Ww_' h+e +x +i�.YyY �� r%tom PLAN CHECK VALIDATION
NAME 1/C7 /Cc` /V/9-y
1. NE pTr tIILECTRICPERMIT F;
CONTRACTOR S UTLETS-SWITCHES-RECEP 5.00/1.00
NAME
L� Lic.No� 16LI LIGHTING FIXTURES 5.00/1.00
cHORESs crDR's
ADDPEsU� APPLIANCES-RESIDENTIAL 4.00
TPS4E�, III PHONE PANELS 5.00 DATE OF APPLICATION
ARCHrtFGT
OP SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
.No.L- SIGNS TRANS. 3.00
ARCH OR
ENG.�J 3J nj r M�U /f1T/ PERMIT VALIDATION
ADDPEss :I rC-.�1n LGA SPECIAL CIRCUIT 5.00
/7, /� �� nv EMP.METER OR POLE IN 15.00
AYPLIGANT'9
ADDRESS MOTORS _ _ SEE FEE SCN. (✓�.bK�----J
Y� 0 g- SERVICE CHAN 10.00
0 o LICENSED CONTRACTORS DECLARATION yVI-1 /L�
a u I hereby affirm that I am licensed under provisions of Chapter 9 �L ISSUANCE DATE
we, (commencing with Section 7000)of Division 3 of the Business amJ
<y BLDG. ELECT. PLG. MECH.
,_ m z Professions Code ans r�Qy IKS se is in full force lrcl-.s
Zo 0,n o License lass_ �-Lic.Number_ .1G7 /s os Cupertino 0 01 0
y r w Date f,F�- Contractor_ C Ow 1
a y E BUILOI O PERMI vY'
¢ ¢ < OWNER-BUILDER DECLARATION ,
A 0 w " MISC.- REFER TO ORD -INFO TION; -,
w3 r I ha- vsereby affirm that I um exempt from the Contractor's License
FU0 Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 6.00 VALUATION E/FT.
ss ('ode:Any city or county which requires a permit to construct,alter,
QQ Q improve,demolish,or repair any structure,prior to Its Issuance.also PLED.CONTR. LIG NO. C .4 ELEC.
i w m¢ requires the applicant for such permit to file a signed statement that � �- TOTAL • PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
r i Law(Chapter 9(commencing with Section 7000lof Division3ofthe Ma P
s z o bus -T
tress and Professions Code)or that he is exempt therefrom and QTY. r tPLUMBINO'PERMIT'a&{ „'�: /
¢ H e the basis for the alleged exemption.Any violation of Section 7031.5 gy, S}f; A5, t 'I'i•'-1fi'•✓v' '�. la•a'�ltr-r`.CrLa tit}) STORIES TYPE CONSTR.
aEm by any applicant for a permit subjects the applicant loo civil penally ALTER-DRAIN -WATER (EA.) 4.001
of not more than Five hundred dollars(5500).1:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00
theirOCC.GROUP RES.UNITS
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'."rhe 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-
ments are not intended or offered for sale,If,however,the budding GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
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 on. RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 2000
O 1,as owner of the property,am 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 Professions Code:The Contractor's License Law does not apply
to an owner o1property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
tracthe Contractor's
suchLicencets Lwithamnmactodsl licensed pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACTNO, PARCEL NO.
the lot License Law.
❑ tem caempl under Sec. .e.&P.C.Icor this WATER HEATER W/VENT 4.00
rL'JfUll
Owncr Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
xs� WORK F:RS'COMPENSATILIN DECLARATION WATER TREATING EQUIP. 4.00
V` I hereby affirm that I have acertificuteofcoment toself-insure. ZONING ENG.SITE NO.
•(\
UI a cel ifacme of Workers Compensation Insuranc• or certified
V copy flScc.3800,Lah.C.l. Atz
P y No. Company QW4
❑ ,Cert)led copy is hereby furnished. FIRE SPRINK ENERGY T7
Z O }(Certified p�tite with the city inspection division. MISC.- REFER TO ORD. y❑ N❑ v ❑ N❑
rj{i�I _ .�_
CL W a•CERTI�TF OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u,C.
111 ? COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
Q. D (This section need not he completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
2 hundred dollars IS 100)or less.) w aI- •r' " - .. i
U O 1 certify that in the performance of the work for which this per, ..
LL F mit is issued,I shall not employ any person in any manner so as
Ow becmne suhiect to the Workers Compensation Laws of California.
y Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} N NOTICE '10 APPLICANT: IL after making this Certificate of Ex-
? cnlpflon,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 110=C.F.M) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=r-F.M.) 5.00 SEISMIC FEE
I hereby dffirm 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.CivC.). HEATING UNIT(TO 100,000 B.T.U.) 4.00 iT1/I
Lender's Name GYi/ HEATING UNIT IO VER 100,000 B.T.U.)7.50
Lender's Addressu.0 UfJlEf� ELECTRIC !/�
I certify that I have read this application and state that theabove VENTILATION FAN (SINGLE) 3.00
intormution is correct. I agree to comply with all city and county BOILER-COMP 13 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorise representatives of this city to enter upon the
above mentioned property or Inspection purposes.
gO1LER-COMP (Over 100,000 BTU)EEE FEE SCH. MECHANICAL
Ic
(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
granting of this permit, r
ONT. LIC.NO. MECH.
> TOTAL � � S R_
Ignatu( Appl1Cdn ontractor ale ( TOTA� I
OFFICE COPY