4406 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI. POINT PEN ONLY
BUILDING PROJECT I DENTI FICATION PERMIT NUMBER
aUILOING APPLICATION & PERMIT
ADDRESS ��.�� /J L' 4,1 . _ 4406
Leu / BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S
N _ PLAN CHECK VALIDATION
DTV. ELECTRIC PERMIT FEE
vlsoNE
CONTRACTORS OUTLETS-SWITCHES-RECEP 5.00/1.00
d Ll O
NLIGHTING FIXTURES 5.00/1.00
CONTRACTORS
PPLIANCES-RESIDENTIAL 4.00
PANELS 5.00 DATE OF APPLICATION
aRCRITECT PLAN CREEW7 P.C.NO.
oR /(Qy � [lpf._,.-, SIGNS 6.00
ENGINEER -
uc,NO. SIGNS TRANS. 3.00
ADDDRESS ENG .NG_ SPECIALCIRCUIT 5.00 PERMIT VALIDATION
nv rFEMP.METER OR POLE INS. 15.00
ADDRESSTs MOTORS SEE FEE SCH,
SERVICE CHANGE 10.00 �/�
woo LICENSED CONTRACTORS DECLARATION YISSUANCrE�DATE
o I hereby affirm that I am licensed under provisions of Cha pier 9
,H,r Q aa. (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H y z Professions Code, nd y 'cense is in full fore�and a cc ❑ ❑ ❑ ❑
o i F W License lass Lic.Number �,� L /C C A ^ F 9�/��g
Dote Contractor F/
Q , f J
¢ ¢ w OWNER-BUILDER DECLARATION BUILDING PERMIT
K ;u y 1 hereby affirm that I am exempt from the Contractor's License
M ISC.- REFER TO ORD INFORMATION
rum J Law(or the following reason,(See 7031.5.Business and Professions PERMIT ISSUANCE 6,00 VALUATION $/FT.
Code:Any city or county which requiresaPeon ittoConnruct,ulter,
¢ C 4 O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
A. c ¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w m o. he is licensed pursuant to the provisions of the Contractor's License � f
H z i Law(Chapter 9(commencing with Section 7000)of Division 3 of the fill
c Business and Professions Code)or that he isexempt therefrom and
¢ r $ the basis for the alleged exemption.AnDTV. PLUMBING PERMITy violation of Section 7031.5 IAS T 5 TVPE,/C�ON�STR.
p3 _ by any applicant fora permit subjects the applicant macivil penalty ALTER-DRAIN -WATER IEA.14.00 Ie- V /
of not more than five hundred dollars(SS00).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 p RES.UNITS
Bra, Dmit
their sole compensation,will do the work,and the structure is hot
intended or offered for sale(Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AR EA,CON D. 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 TOTALACREAGE
himself or through his own employees,provided that such improve-
nalare notintended oroffered for sale.IL however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
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 im-
prove for purpose of the.). INDUSTRIAL WASTE INTER. 20.00
❑ as owner of the property, exclusively contracting with
licensedd contractors to construct the
project La 7044,Business LAWN SPRINKLERS-1 INC.5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The who
builds
License Law dues not apply
to tr owner Of property who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contramod s)licensed pursuant to
Him Contractor'spt Linde Sce. SEWER-SANITARY-STORM EA. 200ft/5.00 TRACT NO. PARCEL NO.
❑ lam exempt lender Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.OATE ACC.FILE NO,
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to set&insure,
or a Certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereoflSec.3R0o,Lab. .l.r.¢-/�
Polis N..-Companyre �L(h(EL-` O
0 ❑ J�etlifed copy is hereby furnished. FIRE$PRINK ENERGY T]4
Z Z dCeRifieel� copy is 0 d with,�y. 'ify inspection division.
F O Applicant f•�r�+ /-�__/./L MISC.- REFER TO ORD. Y[] N❑ v E] No
CC W CF-RTIFICATEOFF.XEMPT1OONN FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.LUG.
lL COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
1 NC]
(This section need not be completed if the permit is for one TOTAL Y N v
=) Z hundred dollars($100)or less)
U O I certify that in the performance of the work for which this per- DTV MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued.I shall not employ any person in any manner so as to
0 W become subject to the Workers'Compensation Laws of California.
Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING S7o
} US 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=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.FM.) 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.). H EATING UN IT(TO 100,000 B.T.U.) 4.00
Lender's NamAddress
HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that 1 have.read this application and state that the above 'VENTILATION FAN (SINGLE) 3.00
Information is correct.I agree to comply with all city:end county gOILER•COMP 13 H.P.Or 100,0008.T.U.) 4.00 PLUMBING
ordinances and stale laws relating t0 building construe lion, and
hereby authorize representatives of this city to emcr upon the LBO' LER (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned 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 said City in consequence of the PERMIT ISSUANCE 3,00
worming of this Penn' MECH.CONT. LIC.NO. MECH.
TOTAL
Q24 / A � /3 a°iA TOTAL
>fi§nafSre o Applicant/Contmcmr Dale
OFFICIE COPY