4990 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I OENTI FICATION PERMIT NUMBER
AooAENNG Zo APPLICATION & PERMIT (�(] 0
��fu� Ca D� ILDING -ELECTRICAL-PLUMBING -MECHANICAL a7 x7
OWrNKER'9 w /� • "' +'F ,: i ;•y �h9 PLAN CHECK VALIDATION
VC NAME �� rslfoiPHONE �r dI r� OT?l. ELECTRIC PERMIT FEES'"
Ds�
CONTRACTOR UTLETS-SWITCHES-RECEP 5.00/1.00
NAME C, �,,/ ,1 A/ �L'I�•S LIGHTING FIXTURES 5.00/1.00
� CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
. ADDRESS /� ,/ ///rrr/// S``
A#'1UCA1# -*&PHONE PANELS 5.00. DATE OF APPLICATION
ARCHITECTEQ'Jb 4 Y SIGNS 6.00 PLAN CHECK FEE P,C.N0on .
ENGINEER-^ /� C�V /
'6 �{ 1 LIC.NO. SIGNS TRANS. 3.00
A Fess ENO SPECIAL CIRCUIT 5.00 Sde PERMIT VALIDATION
e I J& /l.�<?9 Iv EMP.METER OR POLE PAID 15,00 r
APPLICANT'S MOTORS SEE FEE SCH. J .
ADDRESS
SERVICE CHANGE IQ -00
M O LICENSED CONTRACTORS DECLARATION !s
a u u I hereby affirm that 1 am licensed under provisions of Chapter 9 Cif of CB erfino ISSUANCE'DATE
y Q p (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT, PLG. MECH.
r 0 i Professions Code,an y license is in full farce and effect.
Z Z License Class__Lic.Number ❑ ❑ ❑ ❑
o M H Date�_�� �/� Contractor
Q L f J BUILDING P,ERMIT3'.-•r';
%' ,.
¢ ¢ w ¢ OWNER-BUILDER DECLARATIONi •'INFARMATIGNz
o d ° MISC.- REFER TO ORD ' ' '
K
;w m I hereby affirm that 1 am exempt from the Contractor's License VALUATION $/FT.
FU0 Law for the followingreason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,alter, O
Se ¢< improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
iL -O LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
N:
8 he is licensed pursuant to the provisions of the Contractor's License 3,. z o-Pa wy F ,#
H z i Law(Chapter 9(commencing with Section 7000)of Division 3 of the +1' } } 'T t fyy fl✓ '0`//�.
¢ Business and Professions Code)or that he is exempt therefrom and OTY %a i"}s -PLUMBING PERMIT r, rBF�py.�
¢ f ih<basis for the alleged exemption.Any violation of Section 7031$ a Sc"•x A nu•R�.,'ev • '-, }, '[%til' ORIE " TYPE CONSTR.
a ; by any applicant for a permit subjects the applicant to a civil penalty gLTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(5500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00C. P 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. 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 re through his own employees,Provided that such Improve-
ments
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INCA OUTLETS 4.00
or improvement is sold within one year of completion, the owner- .
.
.GAS-EASYSTEM-OVER 4 IEA) 100 BUILDING 115E
builder will have the burden of proving that he did not build or im- RES IND CON PB Other
prove for purpose of sale.). I N DUSTR I AL W ASTE INTER. 20.00
❑ 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. 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 SPRINKLERS-OVER 5(EA.) 1.00
con Gratis for such projects with a contraclons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
'II am exempt under Sea .B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION 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'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.)
Policy No. Companyyw-A: fdd�o
Q \� ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z /,/yy�, Cert/ifife��c�opy Is Filed with the city inspection division. MISC.- REFER TO ORD.
TppliCan t�j V ❑ N❑ Y ❑ N❑
c - CERTIFICATE OF E MPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.c.
UJ > COMPENSATION INSURANCE PLG.CONTR, LIC.NO. PLG.
1 0 (This section need not be completed if the permit is for one TOTAL V❑ N❑ Y ❑ N❑
=) Z hundred dollars($100)or less.) -:•, { ;2 lya +3 < ,.��,.u+ns" e
U 0 1 certify that in the performance,of the work for which this per ,V I.,-MEC ``^"4' '�+ /;FEEF,i : '°C,�r�`s`a.FEE.EUMMAflY ^• r.
1- mit is issued,1 shall not employ any person in any manner so as to s
LL fit,- w h.;"..,' .�;x rd'- .:.•'A".`Tn`LK P ;.` A+S� - ,
U become subject to the Worken'Compensation Laws of California.
O a Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING A(a s(a
} y NOTICE TO APPLICANT: If,after making this Certificate sa Ez-
F Z emvision you should became subject to the Worken'Compensation APPLIANCE 4.00 PLAN CHECK
provisions io the labor Code, you mull forthwith comply with FEE
C..7 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000QF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=11C.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,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATINGUNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that I have read this applicalion and ,are that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and orale laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
t hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP IDVBf 100.000 BTU)SEE FEE SCH. MECHANICAL
(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 y way accme against said City in consequence of the PERMIT ISSUANCE 3.00
gra - "this pe£ MECH.CONT. _ LIC.NO. MECH. i'p.x; ;w-..x,. .-nl}x:
.TOTALS
DTAL s S-
Signature of Applic on tractor
OFFICE GOPY
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