6413 (2) APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY
BUI LDING PROJECT IDENTI FICATION PERMIT NUMBER
aDIEDING - APPLICATION & PERMIT ^ A
ADORE o C}
r � 2p ot
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL '
13
OWNER'S ,I r'; r I'!a ,JFI t�y" e _ PLAN CHECK VALIDATION
� - QTY. w`ydv '1"tI'ELECTRIC PERMIT `"'ty'y' �FEE9=.
bfCTOR S PHONE •i K. • E
NAMEHAGTofls UTLETS-SWITCHES-RECEP 5.00/1.00
s. Lic.No. LIGHTING FIXTURES 5.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADDRESS '
PHONE PANELS 5.00DATE OF APPLICATION
ARCHITECT SIGNS 6.00PLAN CHECK FEE P.C.NO.
OR
ENGINEER r
uc.NO. SIGNS TRANS. yypa�� 3.00 '
ADDRESS e„D. ° SPECIAL CI '11 IJV 5-DD PERMIT VALIDATION
zIP EMP:METER OR POLE INS. 15.00 c
APPLICANTS MOTORS city Ot CUP"IF FEE SCH. J
ADDRESS
SERVICE CHANGE 10.00
waz
FOO LICENSED CONTRACTORS DECLARATION 40 u D P.4 A..
a u U - I hereby affirm(hal I am licensed under provisions of Chapter 9 O N C AL,a F O ISSUANCE DATE
w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F N i - Professions Code,and my license is in full force and effect t, /.V ❑ ❑ ❑
z o w- License Class_ Lic.Number
0 n I-w DateContactor LA
a ,e s , t F11" ( E S C CT. 7-/-3- 9 JOr _' BUILDING PERMIT
BE 0 M.4 OWNER-BUILDER DECLARATION ^d'r INFORMATION
I'xu g LL F I hereby affirm that i am exempt from the Conlactor's License MISC.- REFER TO ORD
w O a law for the(allowing mason.(Sec.70J 1.5,Businessand Professipns
VALUATION $/FT.
�- Code:Any city orcounty whichrequiresa permit to construct,alter, PERMIT ISSUANCE 6.00 _
6 m ELEC.CONTH. - LIC.NO.
K C4 a improve,demolish,or repair any structure,prior(o its issuance,also ELEC.
o M re the applicant for such permit to Me a signed statement that TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License "� /
F i Law(Chapter 9(commencing with Section 7000)ofDivision 3ofthe t sF. x tiJ;
iQo Business and Professions Cale)Or that he is exempt IM1ere(rom and Q k i` wl/UMBING+PERMIT'a'ip"q';y4I v�'t 4F,EE• y
ICF$ the basis for the alleged exemption.Any violation of Section 7031.5 i _ . . c; ^ ' ,;!'"'> t STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN VENT-WATER (EA.I,q,00
of not mom than five hundred dollars($500).):
❑ I,as owner of the propurty,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
(heir sale compens ion,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:'fire 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 TOTALACREAGE
himself or through his own employees,provided that such improve.
ments are not intended or offered for sale.IL however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4;00
or improvement is sold within one year of completion,(he owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or Dr. RES IND CON PB Dlhar '
prove for purpose ofsale.). - INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ El ❑ El
I,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 Conimclor's License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractods)licensed pursuant to
the Contractor's Limnse Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
❑ 1 am exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 4.00
reason
Date". WATER SYSTEM - 4.00 ACC.DATE ACC.FILE NO.
Own
:NS ON DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate ofconsant to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy Bewail ISec.1100,Lal Cl,
Policy No. Company
U ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z 2 CI Certified copy is Bled with rhe city inspection division.
O Applicant MISC.- REFER TO ORD.
YC] N❑ Y ❑ N❑
I-- y PERMIT ISSUANCE 6:00 FLOOD ZONE A.L.U.C.
tr � CERTIFICATE OF EXEMPTION FROM WORKERS' ,
LU _ COMPENSATION INSURANCE PLG.CONTR. , LIC.NO. PLG. Y❑ N❑ Y❑ N❑
CL O (This section need not be completed if the permit is for one TOTAL
=) 2 hundred dollars CS 100)or les.) - 4s Yya
U O I certify that in the performance of the work for which(his per, QTY. - MECHANICAL PERMIT FEE FEE SUMMARV a y
LL I- mi( is issued,I shall not employ any person in any manner so as to ,
U becomesubjec((o(be Workers'Compensalion Laws of California.
wa Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} Do NOTICE TO APPLICANT: If,after making this Certificate of Ex-
? ensption,you should become subject lothe 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.Mf) 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.NU 5.00 'SEISMIC FEE
I hereby affirm that there is u construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of Elle 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 //0-O
Lender's Address HEATING UNIT(OVER 100,0008.T.U.17.50 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 13 H.P.Or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP to.,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 - CONST.TAX
may in any w}'yac,cIrue a ainsl Said City in consequence of the PERMIT ISSUANCE 3.00
gr of II✓ I MECH.CONT. LIC.NO. MECH.
' I S_J8 14 TOTAL TOTAL
gnu ure is t/Contractor Date I
s •
OFFICE'COPY