14049 -APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENT[FICATION - PERMIT NUMBER
BUILDING APPLICATION & PERMIT '
ADDRESS /- ' 4
��I`1. " 1 w 0 1•7 V BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 14049 4 0 4,9_
OWNER'S
NAME PLAN CHECK VALIDATION
• PHONE
A .N�' Q QTY. ELECTRIC PERMIT FEE
CONTRACTORS ' UTLETS-SWITCHES-RECEP 10.00/1.00 6 ,
NAM
6 s r n r' uc.No. U LIGHTING FIXTURES 10.00/1.00
moo ess'oR's APPLIANCES-RESIDENTIAL 4.00
/BJS �•�q/ Irp - HorvE61 g QI ',Z PANELS 10.00 O DATE OF APPLICATION
ARCHITECT
OR PANELS (OVER 200 AMP) 2000 PLAN CHECK FEE P.C.NO.
ENGINEER /
3 ^ARC ^� !N 'D� uc rv0, 1 SIGNS TRANS. 3.00 3 -
ARCH,
H.OR ENG.
ADDRESS, a �M SPECIALCIRCUIT 5.00 s -� PERMIT VALIDATION
Uh( Z/Mf led /vrk t� ZI` . C TEMP.METER OR POLE INS. 20.00
APPLICANT'S
ADDR�SS MOTORS SEE�F,EE SCH. `.17 1`I(/.nN./r•I^�•��'I
p /\
a //7 SERVICE CHANGE 20.00 //
0 0 0 LICENSED CONTRACTORS DECLARATION /6 /
v I hereby affirm that I am licensed under provisions of Chapter 9 }
I-z n (commencing with Section 7000)of Division 3 of the Business and r It BSUA E DATE
'^ 4 BLDG. ELECT. PLG. MECH.
N i Professions Ca nd my license is in full fo ce an of((ect. _ ._nY414
' 0.- License Class Lic.Number '7 O
4 w r J Dale Contractor VL•7 pS U�Y' - ❑ ❑ ❑
a a w 4 ,OWNER-BUILDER DECLARATION •7 - BUILDING PERMIT
w ° a MISC.- REFER TO ORD INFORMATION
; N I hereby affirm that 1 am exempt from the Contractor's License VALUATION $/FT.
u o 4 Law for the following reason.(Sec.7031.5,Bout essand Professions
i -w PERMIT ISSUANCE 10.00
w> Cade:Any city or county which structure permit to alter,
t[ 2 4 O improve,demolish,orTepair any structure,prior m its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O u requires the applicant for such permit to file a signed statement that TOTAL/ -�
a w$ he is licensed pursuant to the provisions of the Contractor's License /--- PERMIT TO
HZQLaw(Chapter 9(commencing with Section 7000)of Division 3 of the CLLs(�
i O Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
M 1-$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
A. by any applicant for a permit subjects the applicant to a civil penalty - ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($500)):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 oec.GROUP -
'their sole compensation,will do the work,.and the structure is not RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOORROOFAREA,CON D. 5.00
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 5.00 SG.FT,FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
' ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6,00
or improvement 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.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 REB IND CON PB other
❑ 1,as owner of the property,am exclusively contracting with 13 El El 13licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 00 ASSESSORS PARCEL NO.
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 cantmetor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec..,BAP.C.for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM- 5.00 ACO.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-Insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,LabC) /I
q/ Policy No. Company VAImr!b< 1^!
❑ Cert' py is hereby furnished.((f7QO d/�// FIRESPRINK ENERGYT24
Z Z ❑ Ce IOed copy ¢ 01�d with the city I speck n division.
FO Appliest nmyg •kit bge MISC.-. REFER TO ORD. v ❑ N❑ v ❑ N�
� N CERTIFICATEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL Z (This section need not be completed if the permit is for one TOTAL Y❑ N E] Y ❑ N❑
U O hundred dollars US 100)or less.)
I certify that in the performance of the work for which this per- OTY. MECHANICAL PE ,T FEE FEE SUMMARY
LL {- mit is issued,I shall not employ any person in any manner so as to ��
U become subject to the Workers'Compensation Laws of California.
OIL Date Applicant BUILDING
>- N NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
I.. Z emption,you should became subject to the Workers'Compensation APPLIANCE 5.00 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 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sea MICROFILM
30nder's .am HEATING UNIT(TO 700,000 B.T.U.) 8.00
Lender's Name /2p n •F
HEATING UNIT(OVER 100,000 B.T.U.19.50
Lender's Address ELECTRIC
1 certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
information is correct.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMPI3H.P.or 100,000B.T.U.) 6.00
hereby authorize representatives of thiscityto enter upon the BOILER-COMP IOVBr IOO,000BTUISEEFEESCH, 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' PERMIT ISSUANCE - 10.00 CONST.TAX
m 'n any way a against Said City in consequence of the
ant g ft
this p il. MECH.CONT. LIC.NO. MECH.
�6 f _ TOTAL' TOTAL
ignition of pp ant/Contractor to
OFFICE COPY