8929 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATIf _ PERMIT NUMBER
BUILDING APPLICATION & PERMIT 8929
ADDRESS UILDING -ELECTRICAL-PLUMBING-MECHANICAL
k• p
OWNS 'S /fV, 1 - .y, M/ rl _ '^xwt eK 4.t tylf e`N`�"eP W PLAN CHECK VALIDATION
N1ME ! K�OVQ
". - , . ELECTRIC PERMIT' ._ ZFEEI-,z
`{I Wsp PHONE
ONTAME c*ons �j U
NTLETS-SWITCHES-RECEP 10.00/1.00 rj-
`✓ rfinQ C-Jecrri IC.NO. j 7 LIGHTING FIXTURES 10.00/1.00
roNT consPPLIANCES-RESIDENTIAL 4.00
/ODRE55 //11 ���� 95�1 L CVe� n /IxQ�NE PANELS IO.00 ,\
DATE OF APPLICATION
,1RCHrtECTPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE
on
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARCH.ORENG. SPECIAL CIRCUIT S,DO PERMIT VALIDATION
ADDRESS
ZIP TEMP. METER OR POLE INS. 20.00
APPLICANT SAOGRESS MOTORS SEE FEE SCH.
SERVICE CHANGE PAID20.00
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 7�t
at 0U I hereby affirmB
that I am licensed under provisions of Chapter 9 APR 1 ICL A� ISSUANCE DATE
a.
(commencing with Section]0001 of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
FN z Professions Code, m 'cense is in full force and of ec ❑ ❑ ❑
o H K License s - Lic.Number 7
Date= �Cmmrae--- City of CuPertmo
� Q w¢ OWNER BUILDER DECLARATION /�rft 1'' `BIIJILDING PERMIT,:
O L.n-_
r 0 u N 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD 1' •��`LUATI,QRMATIONP`S/F t`
uoa Law for the following reason,(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10,00 ) VALUATION S/FT.
Code:Any city or county which requiresa permit to construct.alter, JO.00
i a, ¢Q improve,demolish,or repair any structure,prior to its issuance,also EC CONTR. /�� LIC.NO. ELEC.
D Be requires the applicant for such permit to file a signed statement that �fi ne t.(CGKC TOTAL Q PERMIT TO
w$ he is licensed pursuant to the provisions ol'the Contractor's License t „•, o _ T
H x r
Law(Chapter 9(commencing with Section 7000)of Division 3ofthe - I*.
a Business and Professions Code)or that he is exempt therefrom and GTY. PLUMBING PERMIT,
,g FEE,..
$ the basis for the alleged exemption.Any violation of$ection 7031.5 . . STORIES TYPE CONSTR,
p ; by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) `5.00
of not more than five hundred dollars($500).1:
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 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. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 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 building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of prgving that he did not build or im- RES IND CON Pe Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 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. 6,00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon.and who ILAWN SPRINKLERS-OVER 5(EA.) 1,00
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITAR VSTORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACG FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby atfirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO,
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.), VE.C�
Policy No.-Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Certilied is filed with th city inspection division._
Z z 54Py R/� gLy�ti� , MISC.- REFER TOORD. Y❑ N❑ Y ❑ N❑
O Applicant 6 t E
Cc y CERTIFICATEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU O COMPENSATION INSURANCE PLG.CONTH. LIC.NO. PLG. v f-] N❑ v ❑ N❑
(This section need not be completed if the permit is for BeoTOTAL
:) Z hundred dollars($100)or less.) -
O O I certify that in the performance of the work for which this per v sI' ds4 .,:-FEE BUMMARY:N s s r'
GTV. "MECHAN16At:PERMIT .REE`. 's
IL mit is issued, I shall not employ any person in any manner so as to _.
U become subject to the Workers Compensation Laws of California.
y Date - Applicant ALTER OR ADD TO MECH. • 5.00 BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex::
F Z emption,you should become subject to the Worker'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1Q000C.F.NL) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10ADOC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued ISec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.Cl. p
Lenders Name HEATING UNIT(OV ER 100,000 B.T.U.19.50 ELECTRIC O
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct.1 agree to comply with all city and county BOILER-CONP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
rdinances and slate laws relating to building construction, and
hereby authorize representatives of this city to enter upon the 801 LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
bove-mentioned property for inspection purposes.
(we) agree t0 Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
Boa in any way accrue against said yin D quence f the PERMIT ISSUANCE 10.00
Tan It of permi4 MECH.CONT. LIC.NO. MOTAL
7. ''TOTALS
SI'Applicant/ ontracour Date
OFFICE COPY