1064 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI.. POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMI BER
SOILDINcADDRESS APPLICATION & PERMIT 1064
0 S7b✓(Kf C7MRY. 1✓O BUILDING-ELEaC'TRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAMEa� �a OTY. 4v, ELECTRIC PERMIT rtta 74-'F FEE r•
�� ciN40 CL PHONE R II r. _� fi„TA 4 M1T ft.
f CONTRACTORS UTLETS-SWITCHES•RECEP 5.00/1.00
NAMC
(� ORO uc.rvo. v w ILIGHTING FIXTURES 5.00/1.00
�[ DDRESiTDRA K r RESIDENTIAL
4.00A
PHONE W IOU PANELS 5.00 DATE OF APPLICATION
ARRCHITECT SIGNS Fa
ENGINEER 6.00 PLAN CHECK FEE P.C.NO.
{
LIC.NO. SIGNST N5. 3.00
ARCH OR ENG. SPECIAL Cl T 5.00 PERMIT VALIDATION
ZIP EMP,METER OR POLE 15.00
APPLICANT'S MOTORS
ADDRESS ' SEE FEE SCH.
SERVICE CHANGE 10.00
woo LICENSED CONTRACTORS DECLARATION
<In u I hereby affiren that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
I-z (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r y i Professions Cods��ssseerr�3�my license is in full fD a0d f . ❑ ❑ E]0. - Licen lass�[Y -Lic.Numbee �'°9f
NF w Date JJ_��-�I�_Contractor
a ar< OWNER-BUILDER DECLARATION ;':M BUILDING PERMIT%FS
D REFER TO ORD "::L+"INFORMATION'�'r_''=✓'_
30;LL m 1 hereby affsrm that 1 am exempt from the Contractor's License MISC.- VALUATION SIFT.
Law for the following reason.(Sec.703 1.5,Business and Professions PERMIT ISSUANCE 6.00 /
a m Code:Any city or county which requiress permit to construct,alter, IFr� 0 O a
¢< improve,demolish,or repair any structure,prior to its issuance.also ELEC.CONTR. LIC.NO. ELEC.
F 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 ,7
i Law(Chapter9(commencing with Section 7000)of Division 3 of the Y- d••5 T X7.4 p ".:i x'� --I - '^ �t 7000 CDH. q(•O
i i c Business and Professions Code)or that he is exempt therefrom and OTY jisfP.LUMBING'PERMIT � LwFEEty
¢F•$ the bails for the alleged exemption.Any violation of Section 7031 5 'S.v@. '11 x 9 %'W Y`, ec• T's Ij �;,. :i�'�, STORIES TYPE CONSTR.
a by any applicant for a permit subjects the applicant to a civil penalty gLTER•DRAIN IL VENT-WATER (EA.) L00
of not more than five hundred dollars(S500),):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2,00 oOC.GROUP RES.UNITS
their sole com ensuion,will do the work,and the structure a not
intended or offered for sale (Sec. 7004, 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• GAS•EA.SVSTEM-11NC.40UTLETS 4.00
mens arc not intended or offered for sale.If,however,the budding
or improvement is sold within one year of completion,the owner GAS•EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder w01 have the burden of proving that he did not build or im- RES IND CON Pe Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ 1,a 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 of property who builds or improves thereon.and who LAWN SPR INKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contmetons)licensed pursuant to
the Contractor$License Law. SEWER-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
Date Owner WATER SYSTEM 4.00 Act.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that 1 have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,ora cenified
copy thereof(Sec.3800,Lab.C.). • a
Policy No. Company M/SS/I di //!L6 a
0 ❑ Certified copy is hereby furnished. FIRE SPR INK ENERGY T-24
Z Z ❑ Cenif cop is R ity inspection division.
O Applicant h the � MISC..
REFER TO ORD. Y ❑ N❑ Y [3 NE]
~ m
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
fY
W COMPENSATION INSURANCE PLG.CONTR. LIC.N0. PLG.
d O (This section need not be completed if the permit is for one TOTAL V E] N❑ V E] N[3
Z hundred dollars IS 100)or less.) ., ! . - -' ' I -
U O I certify that in the performance of the work for which this per- QTV
0 ,: 1NECHANICAL PERMITI.' .FEE FEE-SUMMARY
u. mit is issued,I shall not employ any person in any manner so as to -- :,,-t '
IF. „
OU become subject to the Workers Compensation Laws of California. - -
become (.)
d Date Applicant ALTER OR ADD TO MECH. 4.00 d �-
} N NOTICE TO APPLICANT: If,after making this Certificate to Ex
? em vision you should become subject to the W forthwith
Compensation APPLIANCE 4.00 PLAN CHECK
provisions m the Lobar Code, you must forthwith comply' with FEE
67 such provisions or this permit shall be deemed revoked.. AIR HANDLING UNIT(TO 10p00C.F.M) 3.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.EM.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agent)'for EXHAUST HOOD (WITH DUCT) 2.00
the eCvrmance of the work for which this permit is issued(Sec. HEATING UNIT IT 100,000 B.T.U.) 4.00 MICROFILM
Lender's Name H EATING UN IT(OV ER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
• I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all Lily and county BOILER 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 1301LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned 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 CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
gra t, fthis permit MECH.CONT. LIC.NO. MECH. r'+• "' u„y( ,•, e
64 10 2z�� 7/?-� TOTAL .TOTAL' 9i r
Signature of nt( On actor Date
OFFICE COPY