4734 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT I IDENTIFICATIONPERMIT NUMBER
BUILDING •
ADDRESSAPPLICATION & PERMIT 4734
/ R BUILDING —ELECTRICA L—PLUMBING—MECHANICAL
OWNER'S - PLAN CHECK VALIDATION
�C. NAME
•�X.X ,7 QTY. ELECTRIC PERMIT FEE
8-1 S, PMONE<-�`��
NnmERacroRs OUTLETS-SWITCHES-RECEP 5.00/1.00
02 e0A1S7- LIC.NO. ILIGHTING FIXTURES 5.00/1.00
CONTRACTORS
ADDRESS
- 2 PPLIANCES-RESIDENTIAL 4.00
v REss
f /426 eOW/.P*4o A/—L—PNONCNE Z47 PANELS 5.00 DATE OF APPLICATION
ORCNITECT SIGNS 6,06 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00 -
AARCH.OR DDRESS ENG SPECIAL CIRCUIT 5,06 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS
A
APPLICANT
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
.,o 2 LICENSED CONTRACTORS DECLARATION / y/1;3
<z U 1 hereby affirm that I an licensed under provisions of Chapter 9 - ISSUANCE DATE
H Q w (commencing with Section 7000)of Division 3 of the Business and - BLDG. ELECT. PLG. MECH.
H z Professions Co ,�n license is in full for an a efft ❑ ❑
z O — License Class Lic.Nmnber 4 oEMA
o m L o Dale/... /A� Contractor f y aV-4 ( / �/ 8
er y s ( II� DNL—/ O� IRI. A O ` BUILDING PERMIT
O w u OWNER-B LDER DI: ARA O I MATION
w ;A H I hereby affirm that I am exempt from the Contractor's Li me MISC.— REFER TO ORD
I� 04 Law Fortin,following,.xim.(Sec.7031.5,Business and Professions PERMIT ISSUANCE VALVA S/FT.
� — -' Code:Any City or county which requiresa permit to construct, 6.00 �p'I�
re Q ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEG CONTR. LIC.NO. I ELEC ��` � Q
O w requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
1110 I
E
$r4 .he is licensed pursuant to the provisions of the Contractor's License �` p
. HI> Law(Chapter 9(commencing with Section 7000)of Division 3 of the
< Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ r $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
ag; by any applicant for a permit subjects the applicant loacivil penalty ALTER-DRAIN -WATER (EA.) q.00i9V s r
of not more than five hundred dollars(55000.):
❑ I,as owner of the property,or my employees with wages as 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.
melts are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I1NC.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 burden of proving that he did not build or im. RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
O 1,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 ASSESSORSPARCEL NO.
and Professions Code:The Conlmclor'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 contractm(s)licensed Pursuant rI
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ Ium exempt under Sec. ,B.&P.C.tiu this WATER HEATERW/VENT 4.00
reason
Vale Owner WATER SYSTEM 4.00 gGC.OATE ACC.FILE NO.
WORKF.RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that 1 have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
X copy thereof(Sec.3800,Lab.C.).��RM�` wS•,
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certifi, is r, th inpetion diiso
O)( ApplicanTe
MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ rv❑
N CERTIFICATE OF EXEMPTION 17ROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C. .
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This section need not be completed If one permit is for mn, TOTAL Y E] N❑ Y❑ N
Z hundred dollars(5100)or I.,)
V O I certify 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.
w Dale Applicant BUILDING TSa
IL, ALTER OR ADD TO MECH.' 4:00
} N NOTICE TO APPLICANT: If,after making this Certificate sa Ex-
? eruption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must comply with FEE
U - sllcln provisions or this permit shall be deemeddmvo revokea d. AIR HANDLING UNIT(TO 10,000GF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=0C.RM.) 5.00 SEISMIC FEE d
1 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. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ.0.). -
.
Lender's Name HEATING UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that 1 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-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOI LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly 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
granting of this permit MECH.CONT. LIC.NO. MECH.
_-?, c amu,( TOTAL TOTAL .
Signature of Applaaml/Contractor I Dalf
- OFFIC@ COPY