2612 /jPPLICANT TO FILL IN INFORMATION WITHIN RED LINES -'USE BALI_ POINT PEN ONLY 49)
BUI LDI NG PROJECT I DENTI FICATION PERMIT N MR
BUILDING APPLICATION &'PERMIT
ADDRESS � ) /
BQd BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 1
O"AMWNEER'$ C/ I PLAN CHECK VALIDATION
6 NL-/"Q CITY. ELECTRIC PERMIT FEE
CONT TORS
NAME UTLETS-SWITCHES-RECEP 5.00/1.00
G P 546/1rM.N0 LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S n PPLIANCES-RESIDENTIAL 4.00
ADDRESS /1.10uN TAIN ✓/ry
/0 1,9 Y71YKAI 1. RO PHONE y(1/-O(-/O PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CRECK FEE P.C.NO.
OR � �/�� /7uW111L$Lase -
ENGINEER
/346 CV SIGNS TRANS. � 3.00
ARCH.OR ENG.�al 7 a L C,1,.fh INS hL PERMIT VALIDATION
ADDRESS ll SPECIAL CIRCUIT 5.00
Ak-L-0 /4.1-TD Gk Z P .jo TEMP. METER OR POLE INS. 15.00
APPLICANrs Q MOTORS SEE FEE SCH. 911
ADDRESS //DOQ `le L F12 /C )U 9-INO C O/ - SERVICE CHANGE 10.00 OoLICENSED CONIRACIORS DECLARATION ' 3/"
¢ i I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
N a w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H w z Professions Codc un m license is in full fort•CI, eft ❑ ❑ O
oz m o License C ass s _ Lic:Nwnber V
H w L J Dale Contractor
a sz y
¢ as
OWNER-BUILDER DECLARATION BUILDING PERMIT
aa" MISC.- REFER TO ORD INFORMATION
E
g y I hereby affirm that nm exempt from the Contractor's License
F ¢o ¢ Law for the following reason. 7031.5,Business and Professions pERM1T ISSUANCE 6DD VALUATION $/FT.
-' Code:Any city or county which requires a permit to constDwt,.Iteq
S 2 Q Q improve,demolish,or repair any structure,prior to its issuance,also $LEC.CONTR. LIQ N0. ELEC. /O ✓v v
a D arequires the applicant for such permit to file a signed statement that TOTAL
wSe.$ he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
F z i Law(Chapter9(commencingwilh Section 7000)of Division 3 oflhe �.4. /A1J7'e;,C/
4 o Business and Professions Cade)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
M H B the basis for the alleged exemption.Any violation of Section 7031.5T -BT 1 TYPE CONSTR.
a3 by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) q-DD 1
of not more than five hundred dollars(1500).):
❑ I,as owner at the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 df ,G pW RES.UNITS
their sole camp a Fixation,will do the work,and the structure is not y pI Ep�CI l'(fO
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 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
menu are not intended or offered for Sale.If.however,the building GAS-EA.SYSTEM-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 hurnen'of Proving that he did not build or im-
provefor purpose ofsle.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB Omer
0 1,as owner at'the property,am exclusively contracting with ❑ ❑ ❑ ❑ 0
licensed contractors to eonvGuct the project ISec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Cade:'Ihe Contractor's License Law does not apply
m an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts To such projects with a contraolons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
Cl I um exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM - 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof Sec.3600,Lab C.
Policy No. Company
O ❑ Certified copy ishercby furnish[ C&J JrY.J 1 FIRESPRINK ENERGY T-24
Z 21 ❑ Certified y i file with OIt oily inspection division.
O Applicant � i 6v MISC.- REFER TO ORD. Y [D N� v [] NC]
0: W C17R'I'IFICA'Df OFEXE.MPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
Lu > COMPENSATION INSURANCE. PLG.CONTR. LIC.NO. PLO. Y N� V N�
(L O (This Section need not be completed if the permit is for one TOTAL
D Z hundred dollars($100)or less
U O 1 certity that in the performance of the work for which this per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F 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. o
i Date . Applicant ALTER OR ADD TO MECH. q,00 BUILDING O d f-Z
>_ m NOTICE TO APPLICANT: If,after making this Certificate of Ex-
? Antiguan,you should become subject to the Workers'Compensation APPLIANCE 4.00 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=C.F.M.) 3.00
CONSTRUCTION 1.17NDINC AGENCY AIR HANDLING UNIT(OVER 10=C.EM.).5.00 SEISMIC FEE '11P_
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. 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
Lender's AddasNames ELECTRIC
1 certify that I have read this application and state 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(3 H.P.or100,000B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. 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 3.00 CONST.TAX
may in any way accrue against said City in consequence of the
got ndjlty�t•�{this eryiljj_'1. ,f Z MECH.CONT. LIC.NO. MECH. G
x / Lr.DILIlI1,L��er, &-c, -'r'. - TOTAL TOTAL
Sil nature of Applicunt/Cantractor Date
OFFICE COPY