6019 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
s N'O on' t�-• Dt A1J2 j}s ��,5 APPLICATION
PPLICATION & PERMIT
6WLDI
AoDRESv BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
' ECH'ANxI�CA
Lj_
- 6019
VALIDATIONPLAN CHECKOwrvERS - TVI
"aME O �: - ELECTRIC PERMIT FEE'!
UR VANnF
PHONE & N f
COMERacTons - UTLETS-SWITCHES-RECEP 5.00/1.00
mR Sit LIC,No-117299 LIGHTING FIXTURES 5.00/1.00
ADDRESS ,
CONTRACTOR PPLIANCES-RESIDENTIAL 4.00
ADDRESS Afx� ry1,�I (��1 �/r
~ ` PHF�)ES_ 0a1 PANELS 5.00 DATE OF APPLICATION
ARCHITECTaylA1Y DAy1�1`- Pr v SIGNS 6,00 PLAN CHECK FEE P.Q N0.
DR
ENGINEER `
' �-E alas No. {O.SU7 SIGNS TRANS. 3.00
AARCHDORESR ENG.
PrO, /? SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
SII $' pJmau rA ZIP EMP.METER OR POLE INS. 15.00
APPLICANTS
f
aOORESS ( MOTORS, SEE FEE SCH.
_7VI �v VQO E Y'�"' Ca SERVICE CHANGE 10.00 /A
Woo LICENSED CONTRACTORS DECLARATION
a u U I hereby affirm that 1 am licensed under provisions bf Chapter 9 - - ISSUANCE DATE
n a N (commencing with Section 7000)c f,Divisfon 3 of the Business and BLDG. ELECT. PLG. MECH.
r w z Profess.sC Cod license is
is in full roll d e of O ❑ El zm aLicense Cc.Number
9 m - lc Contractoril� -
P ' E - "BUILDING&ERMIT
a ma OWNI:R.BUILDER DECLARATION t�� s�1t`* �f-'
a u ''?:�INFORMARION
F o u m I hereby affirm that I am exempt from lire Comr-clor's License MISC.- REFER TO ORD
y' P VALUATION f/FT.
r .. o.Qi Law for the fallowing reason.(Sec.7031.5.Businessend Professions PERMIT ISSUANCE 6.00 ,il
Code:Any city or county which requires permit to construct.alter, /y"(;,a1
¢ ,¢0 .improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC:NO. ELEC.
O¢ requires Ore applicant for such permit to file a signed smlemenl that TOTAL PERMIT TO
n w m 60
u. he is licensed Palomar to the provisions of the Contractor's License
r Law(Chapter 9(commencingwilh Section 7000)of Division 3 ofthe dd y' ` v + ''' sat
zo Business and Professions Code)or that he a exempt[bereft and QTYf .pU Pr,LUMBING,^;�PE,RMIT
¢ H m the basis for the alleged exemption.Any violation of Section 7031.5 '�L: { - uI 'w'' �' ` F'wn^ STORIES TYPE CONSTR.
A. by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN&VENT-WATER (EA.) 4.00 p
of not more than five hundred dull..(1500).1: 01 CU OItIRo -
❑ h as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCa GEOUP RES.UNITS
Iheir sale 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 docs not apply to an owner of
property who builds or improves thercon,and who does such work FIXTURES-PER TRAP 4.00 SD.FT.FIECOR AREA TOTAL ACREAGE
mints are not
oor wnemployees.for Sale.If,ed that however,the
improve- GAS-EA.SYSTEM-11NC.4 OUTLETS 4.00
mems are noe tis Sold within ion year o If,mpleveq the building
or improvement is sold within nue year of lie didl ion,the ownerGAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not buil)or am. RES IND • CON PB Other
Prove forapurposes owner of she.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the properly,nm 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 Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contrathe Contractor's
o is ctor'sr License
projects with a coNmctnrts)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO. PARCEL NO.
the Cont for Such
License Law.
❑ I am exempt under Sea ,B&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Dale WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSAT ION DECLARATION WATER TREATING EQUIP.. 4.00
I hereby affirm that l have a certificate arconsent to self-insure. ZONING ENG.SITE NO.
ur a certificate of Workers'Compensation Insurance,or u certified
Copy there cc 00.Lab.C.��
Policy No.�01r(Company lClSY➢�1Y'o=a'L7_
(] ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z G0.Cerificr is�fled dr 1p� ty,�ns tion division.
ApplicantlYRt!► ll/Ri1ATbva'[ MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
~ rnPERMIT ISSUANCE 6.00 PL000 zoNE A.L.U.C.c.
Cr CER-1'1' -i(E OF IiXIiMPTION FNDM W(1RK ERS'
W COMPENSATION INSURANCEPLG.CONTE. -LIC.NO. PLG. '
LU O (This section need not be completed if the permit is for one r TOTAL Y❑ N❑ Y❑ N❑
Z hundred dollars(1100)or less./
U O 1 certify that in the performance of the work for which this per pTrYr:t { MECHANICAL PERMIT`- 1 FEE - -FEEISUMM"Y ,019+^. "
W F mil Is issued,I shall'not employ any person in any manner so a lir .ys« x -
U become subject to the Workers'Compensation Laws of California.
0 w Date Applicant- BUILDING
Is. ALTER OR ADD TO MECH. 4.00
}
to NOTICE you
Should
If,after making this Certificate sa Ex-
F. Z enmtion,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 NIT(TO 1Op000F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IO,ODDC.F.M.) 5.00 SEISMIC FEE S
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. 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 ELECTRIC '
Lender's Address
I'certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information isicorrect.I agree to comply with all city and county PLUMBING
ordinances and stale 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 BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property forinspection purposes.
(We) agree to Save, indemnify and keep harmless.the City of MISC.= REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which 'CON I ST.TAX
may in any way accrue against said City in consequence'of the PERMIT ISSUANCE 3.00
n Is palmi. MECH.CONT. LIC.NO.. To
` rr t TOTAL Y
IX
way LOt1e.
Signature of Applicant/Con rector all
OFFICE COPY -