5158 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
jrM INR APPLICATION & PERMIT
[ ADDRESS O`
_� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 5158
In r OwNEH's, PLAN CHECK VALIDATION
"AME W 1„ I-"�S OTY. `r �+'�EIECTRIC PERMIT1 "f ii2' I'4 tEE"+,l
PHONE
coNDwcr,OHs OUTLETS-SWITCHES-RECEP 5.00/1.00
NAME
\ Coyl s .NO. ' Iq LIGHTING FIXTURES 5.00/1.00
CONTRACTORS �6 PPLIANCES-RESIDENTIAL 4.00
ADDRESS Y DIdb
PHONEPANELS 5.00 DATE OF APPLICATION
ARGUTECT y SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR I f
ENGINEE
uc.ND. SIGNS TRANS. 3.00
g
RCH.DR ENa (�(o SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
DDIiE55 //77
S 12 S+ z171SIIrrEMP.METER OR POLE INS. 15.00
APPLICANTS H MOTORS SEE FEE SCH. ( I/��
AOOES$ `�
SERVICE CHANGE 10.00
-00 LICENSED CONTRACTORS DECLARATION
G U u I hereby affirm than I am licensed under provisionsof Chapter 9 ISSUANCE DATE
maw (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F N z Pndcssions Code m,� 1 myjiecnsc is in full forµ n f'•e
z O w- License Cla' G'll X_'4�Lia Number l 0
Q r w Dale <t t- Contractor
y s w 1 BUILDING•PERMIT
k Q Q Q a OWNER-BUILDER R-BUT LIIIiR DIiCLARA'[ION
o a D MISC.- REFER TO ORD ,INFORMATION4',
X
LL N 1 hereby allinn Thal I am exempt from the Contractor's License
LLoj Law for the following reason ISec.703L5,tlusinessand Professions PERMIT ISSUANCE VALUATION $/FT.
� - Code:Any city or coon ty whidh requirnsa permit toconstmet,alter, 6.00
Q 2improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO.
ELEC.
O Q requires the applicant for such permit to file a signed statement that TOTAL PERMI TO
Q w m�` he is licensed pursuant to the provisions of the Contractor's License
F z i
Law(Chapter ii(commencing with Section 7000)of Division 3 of the
- a Business and Professions Code)or that-he is exempt therefrom and QTY. PLUMBING PERMIT FEE
H o the basis for the alleged exemption.Any violation of SCCtirn 7031.5 STORIES TYPE CONSTR.
ate - 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(S500)J'.
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 2.00 OCD.GROUP RES.UNITS
Pe 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:'fire Contractor's License Law does not apply to an owner of
property who builds or improves Omreon,and who does such work FIXTURES-PER TRAP 4.00 SD.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsare not intended orofferedfor sale.If,Imwever,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
or improvement is sold within one year of Completion,Ore owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or am- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
Ll I,as owner of the property.en exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044.Business LAWN SPRINKLERS-I INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code: I'he Contractor's License Law does not apply Q
m an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
r contracts for itch projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200f[/B.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ 1 am exempt under Sec. B.&P.C.for this - WATER HEATER W/VENT 4.00
reY an
t Owner p_VtFr- _. Dote WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby infirm that I have a cerliliem,of consent to uhf-innue. ZONING ENG.SITE NO.
Ora certificate of Workers'Compc neItion Insurance,or a certified
copy thereof(Sec.3500,Lab.C.lts 0"
Policy No. Compnny
O ❑ CetlificdcoPyisherebyfurnished, FIRE SPRINK ENERGY T24
ZZ
CertiOcd copy is filed with the city inspection derision. REFER TO ORD.
Fp APP leant MISC.- Y[] NE] YE) N❑
� y CERTIPICAT'li OF lrIiMPTION FROM WORKERS, PERMIT ISSUANCE 6.00 FLOOD ZONE A,L.UC.
❑-I > COh1PENSATION INSURANCE PLG.CONTR. LOC.NO. PLG.
d ffhls wefon need not lie completed if the permit is for One TOTAL V❑ N❑ Y❑ N❑
Z) Z hundeddollnrs(SI0()o11c.o.)
U O I certify that in the performance of the work for which this per-. DTV. MECHANICAJ-PERMIT FEE FEE SUMMARY*,
LL )- mit is issued,I shall not employ any person in any manner so as to
Ow beconmsuhject to the Workers Compensation Laws of California. BUILDING
ume Applicant ALTER OR AD TO MECH. 4.00
} y NOTICE TO APPLICANT: If,after making this Certificate of F;x- 4,00 PLAN CHECK
F Z
Will tion,you should become subject to the Workers'Compensation APPLIANC
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDL NI (TO 10y,O:p00.F.M.) 3.00
CONS'T'RUCTION LENDING AGENCY AIR HANDLI N ( f§AWC.EM.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST D(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ.C.).
Lender's Name HEATING UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
information is
cancel. I ogres to comply with all city and county BOILER-COMP 13 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
hereby es and state laws relating to building construction,terupon
and hereby enlhorize representatives For ins inspection
this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
ahovrmenlianed property Inn inspecUnn purposes.
(We) agree to save, indemnify and keep ham less the City of MISC.- REFER TO ORD.
Cupertino against liahilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 3 CONST.TAX
may in any way accrue against said City in consequence of the
greding of this per lit. MECH.CONT. - LIC.NO. MECH.
�(�/L�d TOTAL �\ TOTAL /
Sigulture It r Appllcunt/Contractor Ilan, t I
OFFICE COPY