2652 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
• BUILDING PROJECT IDENTIFICATION PERMIT
Nurse
APPLICATION & PERMIT
BUILDING 652
ADDRESS/
6 S 6111/43Z,�/[ 9,,;o BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S PLAN CHECK VALIDATION
" � '37a/.- 'L CS^O QTY. ELECTRIC PERMIT FEE
h k-74-'A - PHONE
CONTRACTORS 3sl8gl'J OUTLETS-SWITCHES-RECEP 5.00/1.00
NAME �!
�(-. /�,Y '1 T CD uC.NO. LIGHTING FIXTURES 5.00/1.00
AronS
ADDRESS PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE C.NO.
on
ENGINEER
LIC,No, ISIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
elR EMP.METER OR POLE INS. 15.00 n q
APPLICANT MOTORS SEE FEE SCH.
ADDRESS
13ZL RESgw_( PAA-Ae 4✓' SERVICE CHANGE 10.00
o o LIC17NSI 1)CONT'RAC !'TORS DECLARATION - O
E,u 1 hereby affirm that I am licensed under provisions of Chapter 9 .ISSUANCE DATE
¢ p1 (commencing with Section 7000]of Division 3.1 thc Business.nd
BLDG. ELECT. PLG. MECH.
n i Professions Cmd y��+ndJJay Beene is in full Torc,Ilic�r7 ❑ ❑ ❑
z o m - License-Cllas}_�Y/GY-evil- .Nwnber- /L
0 z w Dale mei 2.L77-zContmetor
Y BUILDING PERMIT
I[ li w ¢ OWNER-BUILDER DECLARATION INFORMATION
o A O MISC.- REFER TO ORD
K
S LL R 1 hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
F LL o J Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
Code: e,d city or county which structure,Boort loco muaTce, ftp
2 ¢ < 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIG NO. ELEC.
-O ¢ R'lmlres the ePphc.nt for such permit to IIIc a signed Statement that TOTAL PERMIT TO
wLa m a- he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
E 4 o Business and Professions Code)or that he is cxennpt therellma and QTY. PLUMBING PERMIT FEE
¢ o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
w by any applicant fora permit subjects the applicant toacivil penaltyoe
of not more than five hundred dollars(SS00L): ALTER-DRAIN&VENT-WATER (EA.) 4.00
❑ 1,as owner of the Property,or my employees with wages V BACK F LOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure Is not
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code The Contractor's License Law does not apply to an owner of
Property who builds o mproves thereon,and who docs such work FIXTURES-PER TRAP 4.00 so.FT.Ftoon AREA TorAL ACREAGE
himself orthrougende ownemployers,for sale.
11,however,
the
improve- GAS-EA.SYSTE - OUTLETS 4.00
musts are not intended or emplo err,pe.IL howcvcs the balding
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
prove for purpose of sale,). I NDU$TR I AO"T2 I T 20.00 REs INo CON PB ones
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor i License Law docs not apply HH
to an owner of property who builds or improves thereon.and who LAWN SPR IN p ® INDEA.) 1.00
entad,for such Projects with a mntraclons)licensed pursuant In
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I em exempt under Sec .B.&P.C.for thls WATER HEATER W/VENT 4.00
reason
Dale Owner WATER SYSTEM 4.00ACc.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING
or a certificmc of Workcri onlpensatum Insurance,or u certified - ENG.SITE NO.
co the. [1$,Nib, �9�399 I�j��]aQQe.L r,Qywb
O ❑ Certihc�gy¢Imreb 1"T"ohed FIRE SPRINK ENERGY T-24
Z Z ❑ Ce cµfl"J yj�yd is f 6th Ole city inspection division. MISC.- REFER TO ORD. Y E] N❑ Y ❑ NE]lical
n,p /Z
PERMIT ISSUANCE 6.00 - FLooDzoNE A.L.u.c.
w CER'I'IPICArF OIs FXP.MPTION FROM WORKERS'
QJ > C041iNSATION INSURANCE PLG.CONTR. LIC,NO. PLG r Oo Y❑ N❑ V ❑ N❑
❑ (This section need not be completed if the permit is for one TOTAL
Z hundred dollars(S 100)or less.)
U O 1 certify that in tern performance of the work for which this Per. OTV. MECHANICAL PERMIT FEE FEE SUMMARY
, F mit is issued,1 shall not employ any person in any manner so as to
U become subject to the Workers''Compensation Laws of California. BUILDING
O w Dat Applicant ALTER OR ADD TO MECH. 4.00
>_ m NOTICI7 TO APPLICANT: If,:deer making this Certificate of F..-
F. emption,you should become subject to the W'orken'Compensation APPLIANCE 4.00 PLAN CHECK
,...visions of the Labor Code, you most 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 AG ENCY AIR HANDLING UNIT(OVER IQOOOC.F.M.) 5.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this pennit is issued(Sea MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
-
I certify that I have read this application and sale that the above 'VENTILATION FAN (SINGLE) 3.00 In
information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and sate laws relating to building ma,truelion, and
Iftreby authorize representatives of this city to enter upon the ,OILER-COMP (Over 100,000 BTU(SEE FEE SCH. MECHANICAL
above mentioned property for inspection purposes.
(We) agree to an, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino .,.lost liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may m any way accru against said City in consequence of the
g(anlln perllliMECH.CONT. LIC.NO. MECH.
e--f Z,Z _' TOTAL TOTAL
Signa rc of Applicant/Conlruclor [)are
OFFICE COPY