6743 �#PLI6ANT TO FILL IN INFORMATION WITHIN RED LINES'— USE BALL POINT PEN ONLY
`!'.. BUILDING PROJECT,IDENTIFICATION -' PERMIT NUMBER
ADDRESS ILDING - - (( ; APPLICATION & PERMIT '
y BUILDING—ELECTRICAL—PLUMBING«MECHANICAL 6743
VOWNERS
'
NA E PLAN CHECK VALIDATION
O'i'V• 'ELECTRIC PERMIT FEE
PHONE. - V
LON CTORS r
NA E j q UTLETS-SWITCHES RECEP 5.00/1.00 "c24
,�I�,-uc.No. t , , LIGHTING FIXTURES 5.00/1.00 '
noon Ess °s's• - PPLIANCES-RESIDENTIAL '4,00
rzPHON E49G—Z ZI3 PANELS 5.00DATE'OF APPLICATION
ARCHITECT - -
OR SIGNS 6.00
PLAN CHECK FEE .P.C.NO.
- '•
ENGINEER -
' , - LIC.No. SIGNS TRANS.- - 3.00 '
ARCH.OR ENG. '
ADDRESS SPECIAL CIRCUIT, 15.00 PERMIT VALIDATION -
ZIP TEMP.METER OR POLE'INS. 1500
APPLICANT s -
ADDRESS i' + MOTORS SEE FEE SCH
- - SERVICE CHANGE 1000 '(\^]�y/I-'('//'�)•
o C z .. + V'
Foo -r b UCEN ED that I a TRA rased u DECLARATION ((/(�YSL
a u .. c I hereby affirm that I am licensed under provisions of Chapter 9 J •+ C/
HA a"' (commencing with Section 7000)of Division 3 of the Business and ISS ANCE DATE
PAIrl
� license . nfProfessions Cole-AVVLNumlblefo,,y - ❑ ELECT. PLG. MECH.
Lice .
Licela 6
D
Contract NO1/ ILs 1zy -
¢ M,w.< _ OWNER-BUILDER DECLARATION V ^t BUILDING PERMIT
INFORMATION
1 hereby affirm that I am exempt from the Contractor's License MISC.— R T
LL O j. Law for the following reason.(Sec.]031.5,Businessand Professions VALUATION $/FT.
t — 'PERMIT ISSUANCE- o
gm�, Code:Any city or county which requires a permit to construct,alter, .00 .
re Q at0 improve;demolish,or repair any, 1�structure,prior to its issuance,also ELEC.CONTR.' LIC.NO.
ELEC.
a
.O LL requires the applicant for such permit to file a signed Statement that TOTAL d o PERMIT TO
w w he is licensed pursuant to the provisions of the Contractor's License -
FZQ Law(Chapter 9(commencing with Section 700()ol"Division 3 ofthe
g 4 O Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE ELe2T
H$ the basis for the alleged exemption.Any violation of Sect ion 7031.5 STORIES TYPE CONSTR.
di— by ant onei than
fora permit subjects the applicant loacivil penally- ALTER-DRAIN IEA'.) 4,00
of not more than fore hundred dollars the ap li -
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE
their sole compensation,will do the work,and the structure is not 2=00 1OCC.GROUP RES.UNITS
intended or offered for sale(Sec: 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 SG.FT.FLODR AREA TOTAL ACREAGE ,
himself or through his own roves thereon,
provided that such such
ove-
mentsamnotintended or offered for sale.If,however,the building, GAS-EA.SVSTEM-111NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER ER.4.(EA.) .1.00
builder will have the burden of proving that he did not build or im- - BUILDING USE
In
for purpose of sale.). x RESP: - INC. CON PS Othar '
❑ 1,as owner of the property,am exclusively contractingwith INDUSTRIAL WASTE INTER. 20.00
licensed contactors: constructtirekur project(Lawd044,Business LAWN SPRINKLERS-1 INC5 V.B. 5.00 - I-. .ASSESSORS PARCEL NO.
and Professions Code:The Conbuilds 's License Law does not apply
to an owner of properly who builds or improves thereon,and who - LAWN SPRINKLERS-OVER 5 IEA.) 1.00
remotely Tor such projects with a conlraclor(s')licensed pursuant to
the Contractor's License Law.1 SEWER-SANITARY-STORM.EA.200ft/8.00 •;TRACT NO: PARCEL No. .
❑, I um exempt und¢rSec. ,B.&P.C.for this WATER HEATER W/VENT q 00
rcawn
Owner Date WATER SYSTEM 4,00 ACC DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP- 4.00
1 hereby of firm that 1 have a certificate of consent to self-insure, - - -
or a Certificate of Workeri Compensalion Insurance,or a certified ZONING ENG.SITE NO.
eopY thereof 66c.3800,I.A.CJ.
Policy No. • ComPanY NC��/Ai4G6.f/J�� , ..-.
0' IX Certified copy is hereby furnished. +
z Certil.ao, y . ' FIRESPRINK ENERGY T-24_
F Adplicam_L!(_gQ/ lLfiv /'L 1C ' MISC.- REFER TO ORD. -` -T❑ . No, v.❑ N❑^
W CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE _ 6.00 'x, FLOOD zorvE A.LU.C.
L COMPENSATION INSURANCE , PLG.CONTR. - LIC.No.
1
0, JThis section need not be completed if the permit is for one TOTAL + ` .v❑ N❑ Y,❑' N❑
Z hundred'dollars($100)or less.) -
U O 1 certify that in the performance of the work for which this per, DTV. - FEE SUMMARY
lL'l- mil is issued,1 shall not employ any person in any manner so as to MECHANICAL PERMIT FEE
O W become subject to the Workers'Compensation Laws of C.liromin. _
Q. Date - Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} N 'NOTICE TO APPLICANT: If,after making this Certificate of Ex=
Z 'einption,you should become subject to the Workers'Compensation APPLIANCE - 4.00 j.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 10A00C.F.NL) 3.00 = I
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.E.M.) 5.00 " ,SEISMIC FEE
1'hereby/affirm that there is a.construction leading agency for EX HAUST,HOOD IW ITH DUCT) 2.00 .
the performance of the work for which this permit is issued(Sec. - MICROFILM
3097,Civ.C.): HEATING UNIT(TO 100,000 B.T.U.)'. 4.00 +
Lender's Name . - .Leader's Address - HEATING UNIT(OV ERI 00,000 B.T.U.)7.50 ELECTR ICT 0`0
I certify that l have readthis application and stale that the above VENTILATION FAN (SINGLE) 300 r
information-isencorrect. I agree tog to ly b•ildh all city and county BOILER H.P.'Or.100,000 B.T.U.) 400 PLUMBING
ordinances and state laws relating to budding consirucliorand
hereby authorize representatives of this city to enter upon'the BOILER-COMP(Over100,0000TU)SEE FEESCH MECHANICAL
above mentioned property for inspection purposes. - _
(We) agree to save, indemnify and keep harmless the City of MISC.- - - REFER TO ORD.
may
i Cupertino aguiay accrue es,judgments, costs and expenses which pERM171SSUANCE v 3.00 CONST.TAX
\\\ may m any way accrue against said City in consequence of the -
gra I+tgofthis Syn t MECH.CONT LIC NO.1 TOTAL, TOTAL
Signature or Applicant/Contractor .Date - -
- r+ • ) OFFICE COPY