6694 (2) ou
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT 1 DENTI FICATION•; PERMIT NUMBER
aDIEDING APPLICATION& PERMIT
ADDRESS ' • - /�//�•��L/A�
oZOo�,� •..0 �'• BUILDING — ELECTRICAL—PLUMBING—MECHANICAL _ 6 V,V
OWNER'S aye#b _ 6 G9
NAME ••1 p t ,l '. . , PLAN CHECK VALIDATION
PITON
oZ�J•J' 1 IS QTY. ,• ' b."`" ELECTRIC:P.�FiMITz`:�x,'v,a xs + a§FF$Ei.
• cy(oJrvrRAcroRs UTLETS-SWITCHES-RECEP 6.00/100
. ' ,4
S'PJ1V\CC-5 LIC.No. LIGHTING FIXTURES 5.00/1.00
CONTRACTOR 5V`
ADDRESS M'f,'Vttk>_D APPLIANCES-RESIDENTIAL 4.00
PHONE ( J-`aQL{O PANELS
ARCHITECT 5'00 DATE OF APPLICATION
OR SIGNS 1 ggg PLAN CHECK FEE P.C.NO.,
ENGINEER' ,
uc.rvo. SIGNSTRANS. 3.00
AHCX.OR ENG.
ADDRESS . SPECIAL CIRCUIT. '5.00 PERMIT VALIDATION
zIP EMP.METER OR POLE INS." 15.00
Ars
ADDDRESSDRESS MOTORS
SEE FEE SCH.
.
SERVICE CHANGE .. -10.00
o0
Foo 'LICENSED CONTRACTORS DECLARATION ftr
a er U Thereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w ¢w (commencing'with Section 7000)of Division 3 of the Business and E
Professions Cod a y license Is in full force and effte Ev
BLDG. LECT. PLG. MECH.
z o y License Class_ Lm Number ❑ ❑ O
4 m r o iz
Date_ContractorLi
te Q w .OWNER-BUILDER DECLAR ION x - "' BUILDING°PERMIT
'x ; ' r ],hereby affirm that.]am exempt from the Contractor's License MISC.— REFER TO,ORDea
FORMATION w -
F.-o J Law for the following reason.fSecr703 t.5,Business and Professions PERMIT ISSUANCE VALUATION - S/FT.
5 vsy Code:Any city or county which requiresa permiltoconstrucl,alteIs 6.00' Qe -
d W Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. I. ELEC. loiI J�'
o r< requires the applicant for such permit to file a signed statement that TOTAL
o. w'a m he is licensed pursuant to the provisions of the Contractors License - MIT
H z a Law(Chapter 9(commencing with Section 7000)oC Division 3 oC the ' ;`,.
e s o Business and Professions Code)or that he is exempt lhcrcfrom and .iPLUMBING';FERMIT
I- the basis for the alleged exemFltion.Any violation of Section 7031 5 5 RIE T CONSTR.
n3 _ by any applicant lata permit subjects the appllcanl loacivilpenaltygLTER-DRAIN&VENT-WATER,(EA.) 4,00
of no[more than five huntlred dollars($500).):
❑ I,as owner of the property,or my employees with wages as ggCK FLOW PROTECT.DEVICE'-
their sole compensation,will do-the work,and the structure is not 2.D0 OCC.GROUP RES.UNITS
.intended or offered fur sale(Sec. ]044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
Property who'builds of improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA .
himself or through his own employees,provided that such improve-
TOTAL ACREAGE
ments am not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4,00
or improvement is sold within one year of completion, the owner- -
builder will have the burden of proving that he did not build or ire- GAS-EA'.'.SYSTEM.-OVER 4(EA Jr 1.00 BUILDING USE
prove for purpose of sale.). - INDUSTRIAL WASTE
'INTER. RE IND • CON -PB Omar
❑ 1,as owner of Die properly,um exclusively'contracting with 20.00' D El ❑ ❑
licensed Contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5:00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 `
contracts for such projects with a contractor(s)licensed pursuant to "+
the Contractor's License Law.' SEWER-SANITARY-STORM 'EA.200ft/8.00 TRACT No. PARCEL NO,
reason
am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00
Owner 'Date WATER SYSTEM 4.00'
ACC.DATE Ace FILE No.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that'] have a certificdle of consent to self-insure, - L - -
or a certificate of Workers'Compensation Insuraryeg,or a certified ZONING ENG.SITE NO.
. - copy thereof(Sec.3800,Lab.CJ.
Policy No.`j_Q$&gnflac��Ged�.�sI
�❑/ Certified copy is hereby furnisTi , FIRE SPRINK ENERGY T24
z•Z • p.Cerlifipy co .is Oled w14b'the city inspection division.
� p Abplicunt / ]. " MISC. REFEtORD.
� 'Y.0IN r ❑ N[CURTII ICA :OFEX MPTION I°ROM WORKERS' PERMIT ISSUANCE -FLOODZONE -A.L.U.C.LLI D COMPENSATION INSURANCE" PLG.CONTR.' LIC.ND.CL O (This section need pot hecompleted if the permit is (or onC Y N .Y N�U O hundred dollars($100)or lessII certify that in the performance of the work for which this per Q1•\r ,'iK• _ „.MFCHANICALsPERMIsFESUMMARVs`&3sLL 1- .mil is issued,I shall not employ any person in any manner so as to �•b codtds4QWbecomesubject to the WorkersCompensation Laws ofCalifornia. _ '} y Date Applicant ALTER OR ADD TO MECH. BUILDING a
rn NOTICE TO APPLICANT: If,after makingthis Certificate of Ek-
.F Z emplion,you should become subject to the Workers'Compensation APPLIANCE PLACHECK'
provisions of the Labor Code, you must Forthwith comply with N
"U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=d F.M.) FEE
3.00 -
CONSTRUCTIONLENDINGAGENCY- AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE ASO
I hereby affirm that there is a construction lending agency(or EXHAUST HOOD (WITH DUCT) 2.00 r
` the performance of the work for which this permit is issued(Sec. 1 MICROFILM -
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.)' 4.00 .
Lender's Nome '
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 _. .ELECTRIC '.: '
Icertify that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct 1 agree to comply with all city and county .PLUMBING
ordinances and state laws relating to building construction, and BOILER=COMPI3 H.P.or 100,000 B.T,U.) 4.00
hereby authorize representatives.of this city to enter upon the - MECHANICAL
above-mentioned property for inspection purposes. BOILER-COMP'IOver 100,000 BTU)SEE FEE SCH.
(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 way accrue against said City in consequence of the PERMIT ISSUANCE -.3.00
gran of 'S permit + MECH.-CONT: - LIC.NO. • MECH.
TOTAL TOTAL` 75 +00
Signatu a ofA plican[/Co racmr D to
OFFICE COPY s