5088 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT 1 DENTI FICATI ON PERMIT NUMBER
OWLDING APPLICATION & PERMIT 5088
ADDRESS �f D
O / S 'id P^IS Ckesk Rif o BUILDING -ELECTRICAL-PLUMBING -MECHANICAL
WNER'5 PLAN CHECK VALIDATION
`. NAME QTY. ELECTRIC PERMIT " FEE. '
MQ VIN PHON
CONTRACTORS UTLETS-SWITCHES-RECEP 5.00/1.00 _
NAME 11
z � ��Gritl6 LIC.No. LIGHTING FIXTURES 5.00/1.00
ConrRAcrOR's PPLIANCES-RESIDENTIAL 4.00
? noDR�ESss I'�r�ye �( I
e�Nj4 `�I PHONE I ��/ PANELS 5.00, DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE I.C.NO.
OR
ENGINEER
Sac,No, SIGNS TRANS. 3.00
ARCH OR ENG. SPECIAL CIRCUIT 5.00 � ,V PERMIT VALIDATION
DDRESSZIP EMP.METER OR POLE INS. 15.00 y�
ADDRESS MOTORS SEE FEE SCH. J
ADDRESS
SERVICE CHANGE 10.00 9��
_ ((
Doo LICENSED CONTRACTORS DECLARATION ��/�/
a u u I hereby affirm that 1 am licensed under provisions of Chapter 9 MAR 5 1984 ISSUANCE DATE
n a"' (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
Z D i Professions Code, my license is in full forcVe 6 G(553 ❑ ❑ ❑
O,2 ,License Class r Lic.Number ja(
9 m r° Date Contractor
Q y I J t ea •,BUILDING PERMIT
¢ ¢ w ¢ OWNER-BUILDER DECLARATION I `-' "INFORMATION -
Woa " MISC.- REFER TO ORD
; N 1 hereby affirm that I am exempt from the Contractor's License
H .. 0O ¢ Law for the following reason.(Sec,7031.5,Businessand Professions PERMIT ISSUANCE 600 _ VALUATION
Code:Any city or county which requires a permit to construct,alter,
a 2< FO improve,demolish,or repair any structure,prior to its issuance,aka ELEC.CONTR. LIC.NO. FLED. Q'V
- DLL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
La S m he is licensed pursuant to the provisions of the Contractor's License ,
� i> Law.(Chapter 9(commencing with Section 7000)ofDivision 3 of the - " "
¢ Business and Professions Code)or that he is exempt therefrom and OT.V. + PLUMBING PERMIT- FEB..
M l¢- °H the basis for the alleged exemption.Any violation of Section 7031.5 _ "-a I ' -1 - s ,a STORIES TYPE CONSTR.
by any applicant for a permit subjects she applicant toa civil Penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
of not more than five hundred dollars 1 S500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 DCL.GROUP RES.UNITE
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 Contractors License Law does not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself re through his own employees,provided that such Improve-
ments
menu a re not through
onempldfor eesale.lf,ed that suhebudding GAS-EA.SVSTEM-11NC.40UTLETS 4.00
or Improvement is sold within one year of completion, the owner- GAS-EASYSTEM-OVER 4 IEA ) 100 BUILDING USE
builder will have the burden of proving that he did not build or im- . . .
REE IND CON PB Omar
prove for purpose of Sale.). INDUSTRIAL WASTE INTER. 20.00 E:] [:] [:] E] C:]❑ I,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 Corumclor's License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to _..`
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
C, l um exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPF.NSATION DECLARATION WATER TREATING EQUIP, 4.00
1 hereby affirm that I have a certificate of consent to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified I ZONING ENG.SITE NO.
f' copy therggjlS' �gg0F�7p I. /0
Policy N6�(.Q�-lCaNf{8 Y
O �Cerlifit copy a hereby furnish FIRE SPRINK ENERGY T 24
Z _❑ ertified�qpy.iy.fJed wjth 1 �cily-urCtl4n division. ❑ 11 ❑ ❑
O A I{cans O e MISC.- REFER TO ORD. v N v N
0: y CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U,C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
D' C (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
D Z hundred dollars[S 100)or less.)
6.7 O 1 certifythat in the performance of she work for which this per. '+ FEE SUMMARY -
LL I- mit is issud,1 shall not employ any person in any manner so ato aT_Y fi MECHANICAL PERMIT,"•.4,. FHH '
U become subject to the Workers'Compensation laws of California.
W Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} m NOTICE TO APPLICANT: IL after making this Certificate of Ex-
emption.you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Cade, you must forthwith comply with FEE
C.7 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT ITO 10,030 C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.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(his permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ,C.).
Lender's Name HEATINGUNIT(OVER 100,000 B.T.U.)7.50
Lenders Address ELECTRIC
♦� I certify(hat I have read(his application and state(hat the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-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 PERMIT ISSUANCE 3.00 CONST.TAX
may in P
a against said City in consequence of the
.� S1anh MECH.CONT. LIC.NO. MECH. ",v'-+ y
�/�� �,/ TOTAL s b
ala�U✓e/ m Y 'yTOTAL-. ".
gnalurAPPlcant Cnmmctor Date / ':
OFFICE COPY