5467 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LOING PROJECT IDENTIFICATION PERMIT NUMBER
(WILDING APPLICATION & PERMIT.
ADDRESS 5467
/oDOr1Wo�L�rE �qI/pt�p BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S /v GOL/LC. • r � �/YG(�-/c f--D PLAN CHECK VALIDATION
NAME /T QTY. ELECTRIC PERMIT FEE
PHONE s-6-11
CONTRACTDDS UTLETS-SWITCHES-RECEP 5.00/1,00
SNAME C
.0•S. S7-e L L,D, c.rvo. /0670(0 LIGHTING FIXTURES 5.00/1.00
1 CONTRACTORSPPLIANCES-RESIDENTIAL 4.00
'7 ADOBE Sa
116,op ICf142DAVf. SAIJTAC dlW.NE 7V-630 IPANELS 5.00 DATE OF APPLICATION
ARCHITECT/ lAi i�' � SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER�✓/ LJf-fA-C7
sec.NS. G fa'2.7 SIGNS TRANS. 3.00
ADDRESS ENG, SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ADDRESS I� -�A
/�3 2N /O� GDS / L/✓�zIP EMP.METER OR POLE INS. -15.00
iC
APPUDANT'S MOTORS SEE FEE SDH.
ADDRESS v
SERVICE CHANGE 10.00
WO LICENSED CON'I'RA(TORS DE LARA'1'ION
<u U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
„ Q m (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECN.
R D z Professions Coded mr license is in full force aAd cffe��� ❑ ❑ ❑ ❑
2: 0 - License Class_ Lic.Number /OG
a xJ Detc 5-14-G'4 Contractor�$•'
w e, OWNER-BUDDER DECLARATION . ';iBUILDIN.G P,.ERMIT+;
O MISC.- REFER TO ORD ��
m "��NFQRM_ATION•iy
wo u r 1 hereby.1foto that I am exenpr form the Contractor's License - VALUATION SIFT.
r I.o 4 I.aw I'..the following reason.(Sec.7031.5.Businessand ProfessionsPERMIT ISSUANCE 6.00 ,1 7((]]p,�t1
rem Code:Any city or county which requiresa permit to construct,alter- ELEC.CONTR. LIC.NO. 4 1 JUY
a o improve,demolish,or repair any structure,prior m its issuance,also ELEC:
O S, requires the applicant for such permit to file a signed statement that TOTAL PEOMIT TO �/J 11
u w m he is licensed pursuant to the provisions of the Contractor's License I J
Fzi
Law(Chapter 9lcnmmencingwith Section 7000)of Division 3 ofthe Il1L�, WI(jil4xiY
4 ao Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT YYYttt
r$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
to 3 - by any applicant for a permit subjects the applicant W a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4,00
of not tons,than five hundred dollars(5500).):
❑ 1,as owner of the property,or fly employees wish wagesas BACK FLOW 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,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 docs such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,Provided that such improve.
naentsme not intended or offered for sale.If,however,the building GAS-EA.SVSTEM-1 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- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 ED ❑ ❑ E] ❑
❑ I,as owner of the property,am exclusively contracting with
IimnseJ contractors to construct the project(Sec.7044,Bminess LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to ren owner(If properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant it,
SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO. PARCEL NO.
the Contractors 6lceose Law.
❑ 1 am exempt under Sec. ,B.&PEC.for this WATER HEATER W/VENT 4.00
rv,lom
Owner . Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that 1 have a certificate of consent to selFinsnre.
or a certificate of Workers'Compensation Insurance,or,certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,1-ab.C.),1LL IAr4Z
Policy No. CrmP,ny -
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified py is Iild with the city inspection division. MISC.- REFER TO ORD.
�I nppnca �.@..�t2- EL C v❑ N❑ v ❑ N❑
F- y/ PERMIT ISSUANCE 6.00 FLOODZONE A.L.U.C.
CC - CERTIFICATE OI'Ex EMPf10N PROM WORKERS'
111 >_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
IL O (This section need not be completed if the permit is for one TOTAL Y❑ NEI V ❑ No
Z) Z hundred doll,,,15100)or less)
U O 1 certify it,.,in the performance of if,,work I'.,which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
kL F mil is issued,1 shall not employ any Person in any manner so as m
U become subject to the Workers'Compensation Laws of California.
U d Datc APPhemnt ALTER OR ADD TO MECH. 4.00 BUILDING
} W NOTICE TO APPLICANT: IL after making this Certificate of Ex-
F Z empHOP,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK q
provisions of the Labor Code, you must forthwith comply with FEE esze 9 L
U such prnsovisioor this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10,000CF.NL) 3.00
• CONSTRUCTION LENDING AGENCYAIR HANDLING UNIT(OVER 10J"C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the p,rlit,manec of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,CN.C.).
Lend,is Name HEATING UNIT(OV ER 100,000 B.T.U.)Z50 ELECTRIC
Lender's Address
I certify that l have read this application and star,that the above VENTILATION FAN (SINGLE) 3.00
I� 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 state lows relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP lover 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
., (We) agree ro 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 of[his rmi MECH.CONT. LIC.NO. MELM.
XgA
M1 5-V-84 TOTAL TOTAL 7J 9
Siphature of Applicant/Contractor Data
OFFICE COPY