1521 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATION
PERM NU
BUILDING APPLICATION & PERMIT r�
ADDRESS G I
//DCO /Udp• GllT7Lrc BUILDING- ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S
-T.; PLAN CHECK VALIDATION
NAME :ELECTRIC PERMIT ', ''r ' , IF E.,
Paz r PHONE •Yy'.
L-NTRACTOAs UTLETS-SWITCHES-RECEP 5.00/1.00 J :Of7
NAME
U S �C LG LIC.ND. 266 f.? LIGHTING FIXTURES 5.00/1,00
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
ADDRESS ( _
-39 p COCrO U �t Pyo e 3-3j 1 PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER se3.00
LIC.NO. SIGNS TRANS. PERMIT VALIDATION
le
^
ARCH.OR ENL' SPECIALCIRCUIT 5.00 le cc'
/ ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00 rE��ADDRESNrs MOTORS SEE FEE SCH.ADDRESSSERVICE CHANGE 10.00woo LICENSED CONTRACTORS DECLARATIO �ce v I hereby affirm that I am licensed under provisions of Chaplet 9CIP1
m <w (commencing with Section 7000)of Division 3 of the Business andOF
BLDG. ELECT. PLG. MECH.
H 0 i Professions Cod!,and my license is in full force and ef!cUPERTI ❑ p-pEl z 0,7,- License Class CS-�C Lic.Number 21
o z w Date 7- l it Contra FEB 1
Q y f 7 ',': BUICDING PERMIT(;. ."�
M tC m< OWNER-BUILDER DECLARATI s • r >.,g
> DAD MISC.- REF TO ORD i INFORMATIONy_.R`-'v-aPrH
X U.ti 1 hereby affirm that I am exempt from the Contractor's License VALUATION S/FT.
o u D J Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANC 6.00 (e,Alp
a Code:Any city orcounty which requiresa permit toconstruct,alter.
5 < p improve,demolish,or repair any structure,prior to its issuance,alio ELEC.CONTR. LIC.NO. ELEC.
.� I�
0 u requires the applicant for such permit to file a signed statement that TOTAL.3i PERMIi TO
A w m he is licensed pursuant to the provisions of the Contractor's License
i Law(Chapter 9(commencing with Section 7000)of Division 3 of the - '
E c Business and Professions Code)or that he is exempt[her and .PLUMBING PERMIT -rx,a FEE;ia,
Be I- the basis for the alleged exemption.Any violation of Section 7031 5 v.! - .- F...+. "1 --'..., rt�i+1 rS'+;: .''f °- STORIES TYPE CONSrR.
A. 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 dollar(5500).):
❑ I,as owner of the property,or my employees with wagesas IBACK FLOW PROTECT.DEVICE 2.00 DCC.GROUP Res.UNITS
their sole compensation,will do the work.and the structure 6 not
intended or Offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Cade:The Contractor's License Law dam nor apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 Sd.FT.FLOOR AREA TOTAL ACREAGE
himself or throughintends ownemployees,for sale.
If.,howded such tmprove- GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
mens are not intended or offered for ale.If,however,the building
I 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. RES IND CON PS Other
prove for purpose of sale.). JINDUSTRIAL WASTE INTER. 20.00
❑ Las owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business ILAWN SPRINKLERS-1 INC 5 V.B. 5.00 A55ESSORSPARCEL NO.
and Professions Code:The Contractor i License Law does not apply
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 conlractorfs)licensed pursuant to
the Contractor's License Law. l6EW ER-SANITARY•STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
CII am exempt under Sec..,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner IWATER SYSTEM 4.00 ACC,DATE ACC,FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that 1 have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compenution Insurance,or a certified
1i copy thereof(Sec.3800.Lab.C.) L 6
7 Policy No. Company LlX
O ❑ Certifiedcopy,sherebyfunnished. KAl w b C,V 4L FIRE SPRINK ENERGY T.24
Z ZA O Certified I'Q is ft •with the city mu tion division. MISC.- REFER TO ORD. ❑ N❑ V ❑ N
❑
O
C
K TIFICAT EXEMPTION FROM WORKERS'' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
E
W _ CO PENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d C1 (This section need not be completed if the permit is far one TOTAL V❑ N❑ V ❑ .NO
Z hundred dollarsf$100)or less.) !•" a
U O I certify that in the performance of the work for which this per- OTV - C MECHANICAL PERMIT 't i: ✓ FEE•" �� :"FEE SUMMARY. k
U. mit Is issued,I shall not employ any person in any manner so as to , i N s v Z.�
O W become subject to the Worker'Compensation Laws of California. r _y� -�" BUILDING
Dale Applicant ALTER OR ADD TO MECH. 4.00
>- l6ia NOTICE TO APPLICANT: If,after making this Certificate of Ex-
H ? emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you most forthwith Comply with FEE
6 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=CF.M.) 5.00 SEISMIC FEE
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(Sea. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name H EATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC 31 DO
Lender's Address
I certify that I have read this application and state that thean C 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-COMPI3 H.P.or 100,000B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP Over 100,000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the Cilof MISC.- REFER TO ORD.
Cupertino against liabilities, mems, Costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in an al n. Said City in consequence of the
gm 'f II' a ee. I MECH.CONT. LIC.NO. MECH.
TOTAL fi'TbTAL�?
Sib col ppli' onUucnar lata
OFFICE COPY
I