5731 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDINGAPPLICATION & PERMIT
ADRESS
1 OREssAl, WIve- 10 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 5731
rvN' ER5 4? L b t,lr Hw-"';',; b.� ,t y.' L PLAN CHECK VALIDATION
r C r r •y2j, r# l h Lr • ELECTRIC'PERMIT��^t."h ' 1EEE
PHo
rRACTo
N xe_ y UTLETS-SWITCHES-RECEP 5.00/1.00
�x L.C.NO, LIGHTING FIXTURES 5.00/1.00
f6NTAA omS�. PPLIANCES-RESIDENTIAL 4.00 oREss r/`
PHONE PANELS 5.00 DATE OF APPLICATION
OgCHITGCi 1w' SIGNS 6- PLAN CHECK FEE P.C.NO,
FNGINEf I� -C I x (A b'
�Y LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00 n
APPLICANT 5 MOTORS - SEE FEE SCH. J
-
SERVICE CHANGE 10.00 pA p
w0 0 LICENSED CON'T'RACTORS DECLARATION
c u- I hereby affirm Ihat I am licensed under provisions of Chapter 9 S EAUATE
a
y a N (commencing with Section 7000)of Division 3 of the Business and ECT. PLG.. MECH.
F.N _ PrtNcaians Code, my license s m 111 lbiyy JJe�d f(O , ❑'
oi _ 0 Licenze Cluxs_ m.Number-Y c X49 (1� ❑'
2 N E J Uate/=7 Contmctar .Til
a f / -BUILDING PERMIT. '_9
re a OWNER-BUILDER DECLARAIION INFORMSITION'
aoa ° MISC.- REFER TO ORD
w 3 u r I hereby affirm that I am exempt from the Contractor's License VALUATION SIFT.
Fu0 J Law for Ole following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00
Code:Any city ourcounty which requires a permit to constmel,alter,
. W10
improv,demolish,or repair any structure pdur to its issuance,also ELEC,CONTR. LIC.NO. ELEC.
0 ae requires the applicant for such permit to file a signed statement that TOTAL pERM11T TO
a w m he is licensed pursuant to the provisions of the Contractor's License OL(J' .T o
H z a Law(Chapter 9(commencing with Section 7000)of Division 3 of the
s 4 0 Business and Professions Code)or that he isexempt therefrom and QTY. PLUMBING PERMIT FEE (F- 71
re I-$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
u ,
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
Of not more than Eve hundred dollars($5001.):
❑ I,as owner cul the property,or my employees with wages as BgCK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sale c mpensatian,will do the work,and (he structure is not
intended or offered for sale (Sec. 1044, Business and Pu0coians DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does sucltwork FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided That such improve-
memsmrthroue net tendedoruffcrcd for oyeesule if,rovided that such
cbuilding GAS-EA.SVSTEM-11NC.40UTLETS 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 sale.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB Other
CI L as owner of the property,mil exclusively convecting with ❑ ❑ ❑ ❑ ❑
licensed contractors to a Contra the project(Sec.7044,of apps LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to antr owner of property w1m builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
oe trusts for such cenjecLs with a uvvrugods)licensed pursuam to
the Cnmmemr's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT No. PARCEL No.
❑ lanl Cxempttmdcr Svc. ,B.&P.C.file this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby Ofinn that 111:1LC a certificate ul'consent to sell-insula' ZONING
Or a certificate Of Workers'Campp tion 11 c,or a cenil ied ENG.SITE NO.
coBy Thereof ISec 3NDQ Lab C 2m
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
z ❑ Certified gp Y s led w'I,I city i specs ion Division.
O ApplicantLMISC.- REFER TO ORD. Y❑ N❑ Y p N❑
OC W (TR'1'IIICCAATEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOOZONE A.L.U.C.
LU > COMPENSATION INSURANCE I PLG.CONTR. ❑C.NO. PLO,
CL O 11 his section nevi or be Completed if The permit is for One TOTAL Y❑ N❑ Y ❑ No
D Z hundred dollem(SI00)or less.)
U O 1 certify that in the performance of the work for which(his per, QTY. MECHANICAL PERMIT FEE FEE SUMMARY
1L F mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compenwtion Laws of Califumiu. /'tea Sy
LJ Dam Allpllcaut ALTER OR ADD TO MECH. 4.00 BUILDING d
} m NOT IC17 TO APPLICANT: If,after making this Certificate of Ex-
emption.you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAWCHECK
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 I0DOOC.F.M.) 3.00
CONSTRUCTION LENDING AGI7NCY AIR HANDLING UNIT(OVER 10p00C.F.M.) 5.00 SEISMIC FEE SU
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 HEATING UNIT IT 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ,C.l.
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.P.50
Lender's Address ELECTRIC
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP J3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of This city (o enter upon the BOILER-COMP(Over 100,000BTU)SEE FEE SCH. MECHANICAL
above-mentioned prop I for inspection purposes.
(We) agree to s e indemnify and keep harmless the City of Misc.- REFER TO ORD.
Cupertino agai osts and expenses which CONST.TAX
may in any wa a '� c ag' ai Ci y in consequen of the PERMIT ISSUANCE 3.00
g us d / MECH.CONT. LIC.N0. MECH.
I rl 2 TOTAL TOTAL 07,
)gnat m of A I IjCOntmclor Date
OFFICE COPY '