12008 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL. POINT PEN ONL .
BU I LDING PROJECT I DENTIFICATI ON PE NUMBER- •i\ )
SoILOiNG APPLICATION & PERMIT 1 20,�
ADDRESS C 7
�V SrL✓za .S �1^ /J �✓ BUILDING- ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S ,, x - 7. I 4r Jp '-M PLAN CHECK VALIDATION }
NAME/'� 1
07, 1. y ELECTRIC PEWIT:
PNorvE
LN'OAMEAACTORs UTLETS-SWITCHES-RECEP 5.00/1.00 •:�
LIC.NO,53 LIGHTING FIXTURES 5.00/1.00
CONTRATORSin/ Sw+>/'4 �<^tg PPLIANCES•RESIDENTIAL 4.00
✓ I\ FI L PHONE �♦ PANELS ` 5.00 DATE OF APPLICATION
ARCHITECT 6.00 PLAN CHECK FEE P.C.NO.
OR SIGNS
ENGINEER 3.00
LIC.NO. SIGNS TRANS.
ADDREss ENO. SPECIAL CIRCUIT 5.0D PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 15.00
ADDRESNTs
AORES$ MOTORS SEE FEE SCH.
6,1-4
(
SCIA' I Q 6,1 PL SERVICE CHANGE �p 10.00 �d/v/�/
w00 LICENSED CONTRACTORS DECLARATION UPLDTI
¢u u I hereby affurrl that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
n<W (commencing with Section 7000)of Division 3 of the Business and U BLDG. ELECT. PLG. MECH.
F D E License
i ,end my license is N full fo ff ❑ ❑ ❑
D'� - License Class Con Number
N w Date Contractor
- J I "re:'FzBU1LDING,PERMITe,p,---,
a w a OWNER-BUILDER DECLARATION _ - `
ca MISC. REFER TO ORD -b` INFORMATION�;r'.Lt,.:
u r I hereby affirm that I am exempt from the Contractor's License �••vALuanoN S/FT.
u.o 7 Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 6.00
: yea Code:Any city or county which requires a permit toconstruct,.mr, �QO
Qao
improve.demolish,or repairany structure,prior to its issuance.also ELEC.CONTR. LIC.NO. ELEC. r
- DLL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
I w$m he is licensed pursuant to the provisions of the Contmcuor's License p
Fara Law(Chapter 9(commencing with Section 7000)ofDivision3ofthe c. iF >} c ; � O!(. .t?OR.46a_� T
s 4 o Business and Professions Code)or that he is exempt therefrom and OTY kf p 4sPLUMBINGYERMIT Rif (''�,/ t 'FEE('
¢F the basis for the alleged exemption.Any violation or Section 7031.5 xae Tl - - .i ,e C,. >3. -8r y+^ A �:+3.Sta(`3'' •f�5 cse STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-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 2.00 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. 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
himselfornot hrough
ownemployees.for sule.
Ii,ed that however,the
improve- GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
mems are not intended or offered far sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or ho RES IND CON PS other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 2000
❑ 1,as owner of the property,am exclusively contracting wi .
th ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPR IN K LERS- 1 INC 5 V.8. 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
contracts 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.
❑ lam exempt under See.-,BAP.C.for this WATER HEATER W/VENT 4.00
reason
Dose Owner WATER SYSTEM 4.00 ACC.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,or a certified
copy thereof(Sec.3800,Lab.C.).iC,W(M C CF A
Policy No. Company ��))
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z ❑ Certified i fits w' th ty inspection division.
H' 0 yr��/} ../' �I- PERMIT
REFER TO ORO. ❑ ❑ ❑ ❑
Applicant mriol-"""�U Y N Y N
to PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
2 CERTIFICATE E EXEMPTION FROM WORKERS'
CL7 COMPENSATION INSURANCE PLG.CONTR. LID.NO.huPLG. Y❑ N❑ Y❑ N❑
CL 2 (This section need not be completed if the permit is for one . AL
hundred dollars IS 100)or less.) ' TOT,�•4
U O I certify that in the performance of the work for which this per, CITY -, :, MECHANICAL PERMIT , , ,FEE FEE BUMMARY'
IL - mil is issued.I shall not employ any person in any manner so as to r{„ P y
U become subject to the Workers Compensation Laws of California.
A. Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F ? emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the labor Code, you must 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 10=C.F.M.) 5.00 SEISMIC FEE S�
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work far which permit is issued ISeC. MICROFILM
3097,Civ
.C.I 1�M HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name-� HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct.1 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
I hereby authorize representatives of this city to enter upon the BOI LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspectionpurposes,
(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 i City in consequence of the PERMIT ISSUANCE 3.00
gra O t isp IL MECH.CONT. LIC.NO. MECH. 'til d;'?'"1
/ 20 TOTAL TOTALu,F'^ 3 y GD
SignaWre of ApplicanllContmclor
at
et�l�'. �=P•:a"':
OFFICE COPY