4575 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS tv yG O 5-TIOK C ALIS`" _ 4575
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S
NAME \ PNONE x,�AYE114 ..-f..).l "• ♦ Q 'f+ V i v4°„ PLAN CHECK VALIDATION
~. 6h"LRSo>J a5 -803 GtY LECTRIC PERMIT, Z ••,h
rr"FEE':
L
-VNTRADTOR5
NAME UTLETS-SWITCHES-RECEP 5.00/1.00
LIC.No, LIGHTING FIXTURES 5.00/1.00
ADDDRESS TORS PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT
OR SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No, SIGNS TRANS. 3.00
ARCH.OR ENO. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
ZIP TEMP.METER OR POLE INS. 15.00
ADDRESS Ts MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00 /
M o LICENSED CONTRACTORS DECLARATION
a U u 1 hereby affirm that I am licensed under provisions of Chapter 9
y Q W (commencing with Section 7000)of Division 3 of the Business and NCE PL
H i Professions Code.and my license is in full farce and effect. BLDG. ELIG. MECH.
0 License Class Lia Number
m r w Dale Contractor
a
Or a OWNER-BUILDER DECLARATION ,.``eyl.:B ILDI ERMITc!$!I i
'u. , :' ^fr` FO ATION.
w 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD M
w 0< Law for the following reason.(Sec.7031.5,Business and Professions 6.00 L S/FT.
-rn PERMIT ISSUANCE s�
Zi' Code: e.demolish,
county any structurep riot to
also
a <0 improve,demolish,of repair any structure,10rfi prior n its issuance,also ELEC.CONTR. LIC.NO. ELEC.
0 LL requires the applicant for such permit to file a signed statement that m TOTAL PERMIT TO$w he is licensed pursuant to the provisions of the Contractor's License
Hza
Law(ChapterProfessions
ode)with Section is exempt
4<ri' 14ir7.Ghr+'?;:i"'-i3"v C"' 141E s2,0 K.4,ad Z'A•U
14 p Business and Professions Code)or that he is exempt Therefrom and CITY t,.?(,d r " PLUMBING'PERMIT -� •,+ FEE'.
¢ H� the basis for the alleged exemption.Any violation ofSection 70315 STORIES TYPE CONSTR,
a3- - by any applicant fFve hemi subjects the 500micanitoaeivil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not mato than five hundred dollars ISS emp
❑ Las owner the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 Oee.GROUP RES.UNITS
their solecompensation,roffered
will do the work.and the structure is not
Code:Th. offered far ml,(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 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 SD.FT.FLOOR AREA TOTAL ACREAGE
.;^Pelf or through his own employees,provided that such improve.''4tarc nal intended or offered for sale.If,however the building GAS-EA.SYSTEM-l1NC.40UTLETS 4.00
`=a7r i nprovement is sold within one year of completion,the owner.
builder will have the burden of proving that he did not build or im. GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 RES IND CDN PB Ulnar
❑ 1,as owner of the property,am exclusively contracting with ❑
licensed Contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 5.00 ASSESSORS PARCEL NO.
El 13
and Professions Code:The Contractor's License Law does not apply V.B.
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 cm ractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for this
mown WATER HEATER W/VENT 4.00
Dale "x, 2-8,3Owner 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-insur,.
or a certificate of Workers Compensation Insurance.or a certified ZONING ENG.SITE NO.
COPY themof(Sec.3800,Lab.C.).
Policy No. Company
.7 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY TP9
Z Z ❑ Certified copy is filed with the city inspection division. V N� v N�
- 0 Applicant MISC.- REFERTOORD.
S = CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
y COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
1 O (This section need not be Completed if the permit is for one TOTAL Y❑ N� V N�
Z hundred dollars,S 100)or less.)
J O I certify that In the performance of the work for which this per. Ory MECHANICAL PERMIT FEE FEE SUMMARY
y.1- mit is issued,I shall not employ any person in any manner so as to
Wbecome subject to the Workers Compensation Laws of California.
Q. Date Applicant BUILDING /0
N to NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 4.00 �a
_ 2 emption,you should become subject to the workers Compensation APPLIANCE 4.00 PLAN CHECK /
Provisions of the Labor Code, you must forthwith comply with +/ S�
.� such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT ITO 10,00011F.M.) 3,00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F. ,) 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
30nde97.r's am - HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lenders Address HEATI NG UN IT(OVER 100,000 B.T.U.17.50 ELECTRIC
I Certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
,information is correct. I agree to comply with all city'and county BOILER-COMOQ H.P.or 100,000 B.T.U.) 4.00 PLUMBING
-stances and stale laws relating to building construction, and
..Eby authorize representatives for ins inspection
this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
.f sovomentloned 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 CONST.TAX
may in any way accrue against mi City in consequence of the PERMIT ISSUANCE 3.00
gr I ofthisperml[. MECH.CONT. LIC.NO. MECH. f�lr
// 2-k.,� TOTAL TOTAL'-' '' 7
lure o pPlicent)Con r Tor Date
OFFICE COPY