6855 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
A�27aC;3/5 _ / Ce- LJD BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 6855
T- .y "�-u a ,L' PLAN CHECK VALIDATION
NGME V
,ry{ �" 5rj„fiLECTHIC,bERM1T :: El$
+ veo»E r=1 $_1" . RAI
ERACTDHIS UTLETS-SWITCHES-RECEP 5.00/1.00
No �0 LIGHTING FIXTURES 5.00/1.00 Su , �bBS
CONTRACTOR'$ 7C
ADDRESS
J`/ I�u AIX1,111 T PPLIANCES-RESIDENTIAL 4.00
.JW / � TPN PONE' p -SJ� PANELS 5.00 F
AOR
RCHITECT SIGNS 6.00 PLAN CHECK FEE' .C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH OR DDRESS ENL. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
zIP EMP.METER OR POLE INS. 15.00
APPLICANT'$
AooREss q� MOTORS SEE FEE SCH.
T' & h" e-) SERVICE CHANGE 10.00
Dai
Foo LICENSED CONTRACTORS DECLARATION
a i w I hereby ul'firm that I am licensed under P OVISLOna of Chaplet 9 ISSUANCE DATE
w a N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. L MECH.
F N z Professions Co ado
y license is in,full force yyJ c ❑ ❑ ❑
Z 0 M - License lass� Lic.Nmber V'
9 y w Contractor_ C e '
g g F N rr- T � IC t o .ERMIT
¢ ¢ w a OWNER-BUILDER DECLARATION A ib v
w ; LL. I hereby affirm that I am exempt from the Contractor's License
MISC.- REFER TO ORD �331TTT3 ' NF.00 770N: '
FU0< Law for the followingreason.JSec.7031.5,Busme"tnd Professions PERMIT ISSUANCE VALUATION; SIFT.
Code:Any city or county which requires a permit,o construct,alter. 6'�
¢ my ELEC.CONTR. LIC.NO.
Q < o improve,demolish,or repair any structure,prior to its issuance,alsD ELEC.
CLL requires the applicant for such permit to file a signed statement that TOTAL ERMIT TO
u w m he is licensed pursuant to the provisions of the Contractor's License
zi
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe �' trei
4 o Business and Professions Code)or that he is exempt therefrom and 1Y1]/. PLUMBING PERMI,L� G
¢ I-$ the basis for the alleged exemption Any violation of Section 7031 5 "k 'vf {, ' y •fg+�ffiYf, a h,T' «_' ara5;l +.11•u S ORIES TY7 CONSTR.
u ; - by any applicant for a permit subjects the applicant ton civil penalty ALTER-DRAIN&VENT-WATER IEA.14.00
of not more than five hundred dollars f 55001.1:
❑ 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 (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,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. GAS-EA.SVSTEM-11NC.40UTLETS 4.00
merits are not intended or offered for sale.If,however,the building
or improvement Is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 guaD G BE
builder will have the burden of proving that he did not build or im- RES IN C N PB Omer
prove 1.as ofor wnerose
of the.l. INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑
❑ has owner of the property,am exclusively contracting with
licensed contractors to construct the project face.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS CELNO.
and Professions Code:The Contractor's License Law does not apply
to in owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1,00
comae is for such projects with a contrnetons)licensed pursuant to
the Contractor's License Law. - SEWER-SANITARY-STORM EA. 200ft/8.00 � I TRACT NO. PARCEL NO.
'J I dre exempt under Sec,-,BAP.C.for this WATER HEATER W/VENT 4.00
lcxlm
Owner Date WATER SYSTEM 4.00
r(. ACC.DATE ACC.FILE NO.
WORK ERS'COM PENSA"PION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Confirmation Insurance,or a certified
cagy thef5 c Be. ab.4J. d27�rileffPLAJ
Policy N [e.L any
0 ❑ Sxrtified ygpy is hereby furnishgit
Z Z ('en i0c/A[4nu4 is d wit a tl a mfpection division. FIRE SPRINK ENERGY T�Z4
~ � Applicant [j�f MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
_ PERMIT ISSUANCE 6.00 .67) —FLOOD A.L.u.C.
K CERTIFICATE OF EXE ION FROM WORKER '
L �_ COMPENSATION INSURANCE P .CONTR. L)C.NO. _ PLG. IC
CL O 41hi tion need not be completed if the per t is for one a. TOTAL v Y❑ No y❑ No
0 2
hundred dollars(SIOG)or less)
V I e Yly that in the performance of the wor or which this per J at
LL l- mit is Issued, I shall not employ any Person i any manner sD as to lei ECNfNIdAk,PEpMI]' `'A. . .v
0 W hecome subject to the Workers Compensati laws of Califomsa. &f �Ti F3 k
a Uate Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} so NOTICE TO APPLICANT: If,after nortinx this Certificate of Ex-
F Z emotion,you should become subject 10 the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the labor Code, yod..at forthwith comply with FEE
U such provisions or this permit shall'be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER tOpODC.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,Cw.C.L HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name H EATING UNIT(OV ER 100,000 B.T.U.)7.50
Lenders Address 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-DOW(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and stale laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP(DN11 W,000 BTU)SEE FEE SCE. MECHANICAL
above-mentioned progeny far 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 Yg any w Seems, against said City in consequence of the PERMIT ISSUANCE 3.00
MECH
/
1' of th' rnil. MECH.CONT. LIC.NO. TOTAL /
Signaaluund of Appli /Contractor Dale wj ✓ J
OFFICE COPY