6367 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT 1 DENT]FICATION PERMIT NUMBER
BmLmNG APPLICATION & PERMIT 6367
ADDRESS
UILDING ELECTRICAL PLUMBING-MECHANICAL
OWNER'Sf=Yx, �A.�,,.A -ylti p ,Y x ( .art• pLgry CHECK VALIDATION
"AME „ ^ OTY- `a ;+a�',.!;EIECTRIC;PERMITIII,�"• StM1.�-F�-:eT
G / Iaf go /Na IL 4k$oRE 5 S q9 ': .. n
CONTRACTOR s��++ UTLETS-SWITCHES-RECEP 5.00/1,00
C OA/5'�RUr.T/6�. LIOND. C/ LIGHTING FIXTURES 5.00/1.00 PAID
CONT AGTCRA PPLIANCES-RESIDENTIAL 4.00
ADDRESS AZ IOe.G-` no PHONE Z ^Q/( PANELS 5.00AY A IcnnDN
ARCHITECTh"W L, SIGNS 6,00 PLAN CHECK FEE D.C.N0,
OR
ENGINEER
11C.NO. SIGNS TRANS. 3.00 City Of Cupertino
ADDRESS E"o' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP. METER OR POLE INS. 15.00
APPLICANT DORS 'B
ssMOTORS SEE FEE SCH.
AOOnsss `1/�J 2
SERVICE CHANGE 10.00 C. J
F a o LICENSED CONTRACTORS DECLARATION
a U I hereby atl'inn that I din licensed under provisions of Chapter 9 BU NCE DATE
mac Icmnmcncing with Section 7000)of Division 3 of the Business and BLD ELECT, PLG. MECH.
i- PRslensianz Code.,�gd my license is in(all fore n eff 30
o i F O/ Licv1 C as, 6-f�Lice Number (s
< x fia
( ' BUILDING PERMIT ,+<;
A ¢ w ¢ OWNER BUILDER DECLARATION a
s o d u ',INFORMATIOW
x 1 herchv affirm that I oat exempt from the Contractor's License MISC.- REFER TO ORD
FLL0e Law for the following reason.(See.7031.5,Buslnessond Pmfe..ioos PERMIT ISSUANCE 6.00 VALUATION S/FT.
Code:Any city or county which reunion a permit to construct,Act, ELEC.CONTE. LIC. ��V�
5 ce ¢ II11prI1Ve.JCmOhih.Or repair any structure.prior 10 IIT issuance.aI50 ELEC.
0 ¢ luires the applicant for such permit to file a signed statement that TOTAL p p-,
d w m v, r ll s licensed pursuant m the provisions of theContractor s License
�� (n ,T/�C1t
i La (Chapter')(commencing with Section 7000)of Division3of the - ,r,
io Business and Prno Coder r that he Is exempt therefrom and OTV. � % 'PLUMBINO PERMIT' 4-,a �'FEE.p
x 1- the basis for the alleged exemption.Any violation of Section 7031.5 ° �> - . STORIES TYPE CON R.
u ; by any applicant lar a permit subjects the applicant to a civil penalty
of not more than five hundred dollars($500).): ALTER-DRAIN&VENT-WATER (EA.) 4.00
❑ L as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP REB.UNITS
their vile compensation,will do the work,and the structure is not
• intended or offered for sale ISec. 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 sa FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedoroffered for sale.If.however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or inlprovemem is mid within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
IS will have the burden of proving that he did not build or im- REB IND O PB Omer
prove for purpose of.le). INDUSTRIAL WASTE INTER. 20.00 RE ❑
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to Construct the project(See, 704,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSES50 SPAHCELNO.
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 contractor(i)licensed pursuant to
the Contractors 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
Owner Hate WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 4.00
I hereby affirm that I have a certificate of consenlto sctf-my"
re.
i or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab CA
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z/ ❑ Certified copy is filed with the city inspection division. MISC. REFER TO ORD.
O Applicant Y N 0 v 0 N[]
CC CERTIFICATEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LL > COMPENSATION INSURANCE PLC.CONTE. LIC.NO. PLG,
d Y N Y No
O This section need not be completed if the permit is for n TOTAL
UZ hundred dollars(Sl001 or less.( a:i<;ya4 ^.•� `"C •` 'w iq,PK na�� - `uf 1'rr
U O certify dim in the performance of flit work for which this per OTY' i MECHANICAL PERMIT' 4l'- 4, `fiFE94 W
v!q,.yR@Q$11A1N/1Rey,
LL H mit s Issued,1 shall not employ any person in any manner m i s to p ^,�7_ ef< 'f {,C, 1 ,z tk; '"
O w Date y�g t Co t Ae Workers C pensaY n Laws pf CaIifo nla. !rJ
Late- TfApPlicantAv �or�t/--•¢i BUILDING
a CI!� 7V--{TC- fPOVPLLL ALTER OR ADD TO MECH. 4.00
} N NOTA (CANT: If,ti ler eking t of ER-
F.. ? coalition.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 ITO 10MC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C,F.M.) 5.00 SEISMIC FEE SZi
1 hereby affirm that there is a construction fending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(See. MICROFILM
3097.Civ.Gl, HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender',Name H EATING UNIT(OVER 100,000 B.T.U.)7.50
Lenders 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 b ' -ng construction, and BOILER-COWP(3 H.P.Or 100,000 B.T.U.) 4.00
hereby authorise represent eS of t ' ?t to enter upon the BOILER-COMP(0.,100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property r inspe' n Sea.
(We) agree to save ndemof an k harmless the City of MISC.- REFER TO ORD.
Cupertino against It.
hies,j gme costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way a rue ag St City in conseruen of e
grantingofthis per i ^ MECH.CONT. LIC.NO. MECH.
DIAL x TPUL
oat f Applicant/Contr Drip
OFFICE COPY