5670 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFIL .ON PERMIT NUMBER
itu"ITHREG APPLICATION & PL.WIT
ADDRESS 5670
BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
• OwNEH3 R"�,�1 Y'Id3 ( tcg •* `-t,, PLAN CHECK VALIDATION
NAME EGTRIC,P RMIT
V /✓/� PHONe . .. fir 's-&''`- .,v :lf.,. t'-' L..
CONTRACTORS OUTLETS-SWITCHES-RECEP 5.00/1.00
UC.No. �� - LIGHTING FIXTURES 5.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
AonREss /
vHOrvE 9 PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER`�✓/s
LIC.NO. SIGNS TRANS. 3.00
ARCH
ADDRESS END. SPECIAL CIRCUIT S.QQ PERMIT VALIDATIO
/f ZIP EMP.METER OR POLE INS. 15.00
AMOTORS SEE FEE SCH.
ADDDRESSDRESS
SERVICE CHANGE 10.00
o ¢ z
F o O LICENSED CON I'RACFORS DECLARA'iION t
¢ u I hereby affirm that 1 am licensed under provisions of Chapter 9 IS ANCE DATE
w Unmmencing with Section]0001 M Division 3 Df the Business anJ BLDG. EL T. PLG. H.
" D i Protex,iuns Code andgVy icanse is in full force d 1 6c ❑ ❑ ❑
z o w - License Cuss Lie.Number
9 m Date-6_ Contractor'
`a y E qty B41C NO'PBBM T' t
¢ ¢ a
IT-
OWNER-BUILDER UFCLA TION Yi
A o a v *: t4,&',INFOR"JJGN
w thereby of erre that I am exem t from the Contractor's License MISC.- REFER TO ORD
3 u '- Y p VALUATION S/FT.
LL o J Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 6.00
m � Code Any city or county which requiresa permit toconstruct,alteo
R ¢
2idemolish.
¢ O improve, emos ,or repair any structure,prior to its issuance,also EI-EC.CONTR
. . LIQ NO. ELEC.
n
D LL tell Wres the applicant for such permit t0 file a signed sutemenl that TOTAL PERMIT TO
I,
m he Is licensed pursuant to the provisions.1 the Gmtr ator i License
r z a
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe " k MFS
Business and Professions Code)or that he is exempt therefrom and GTV m 1PLUMBING PERMIT 1'?_-;w;." ' FEE
¢ o
the basis for the alleged exemption.Any violation OI SeLhon 7031.5 oa "' f 1 '' °7n .^.^. 1 t sfj,k yjy',, STORIES TYPE CONSTR.
A. by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
ulrat more than five hundred dollars(55001.):
❑ I.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 1043, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law docs not apply to an owner of
properly 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
ments are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM. 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- . RES IND CDN PB omar
prove for purpose of sale.(. INDUSTRIAL WASTE INTER. 20.00
CII,as owner ol'the properly,am exclusively contracting with ❑ ❑ Cl ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and PTofcssions 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 Contractor's
License
ts LwilhacontractuRs)licensed pursuant to SEWERSANITARYSTORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the Contractor i License Law.
❑ 1 am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 4,00
reason
Owner Date 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 eunsenl to self-insure, ZONING ENG.SITE NO.
or IT certificate of Workers'Compensation Insurance.or a certified
copy the (Sec.3800,L bC.s.
Policy N��COmpmy
O ❑ Ceol led copy is hereby furbished. O FIRE SPRINK ENERGY T-24
Z Z dY ('erti(ied copy tiled with inspection division. MISC.- REFER TO ORD. Y❑ N❑ Y❑ N❑
O pphcant �!f/�f -__�-
CC va X(T PERMIT ISSUANCE 6.00
CI'RTIFIC OF EXEMPTION FROM WORKERS' FLOOD ZONE A.L.U.C.
LLI > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
D' 0 1'1his section need not he completed if the permit is for one _ TOTAL Y❑ N❑ Y❑ N❑
Z hundred dollars IS 100)or less.)
V O 1 certily that in the performance of the work for which this per-
LLV- mil is issued. I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
a Date- Applm°nlALTER-OR ADD TO MECH. •QQ BUILDING
ii
} N NOTICE 'f0 APPLICANT: If,after making this Certificate of ExJi14-
F z.. 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 10JM0C.F.M) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNff(OVER IQOQOC.F.W 5.00 SEISMIE'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.1 4.00
• Lenders Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
Ho ODDuron 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
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP(Over 100,000 RTUI SEE FEE SCH. MECHANICAL C'
(We) agree to save. indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, Costs and expenses whichpERM1T ISSUANCE Q tti qj"i CONST.TAX
may in any way accrue against mid City in consequence of the
granting Of this wout. MECH.CONT. LIC.NO. MECN.
l� TOT Uw "i TOTAL$,=z_v.
Signator plicant/Contractor Date {;;.':' i
OFFICE COPY