4969 (2) �ICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUI
LOInc cAPPLICATION & PERMIT 4969
.ODRE95
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
� Ovvs RPlu 1/IG N PLAN CHECK VALIDATION
"AME CITY. ELECTRIC PERMIT FEE
PRONE c.c�l'�
i �.r-��1�
NAINuERACTORs UTLETS-SWITCHES-RECEP 5.00/1.00
LIC,No. Z Z LIGHTING FIXTURES 5.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADDRESS
((f Lam. XOnE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6,00 PLAN CHECK FEE .C.NO.
En 9EER
UAa LIC.No. SIGNS TRANS. 3.00
ADD.Ess cede. SPECIAL CIRCUIT 5.DB PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00 f�,,,4a J��
AppuCANTS MOTORS SEE FEE SCH. L J•[,}�C
ADDRESS U
SERVICE CHANG 10.00
,0o LICENSED CONTRACTORS DECLARATION
1984 G U w I hereby affirm that I .m licensed under Provisions of Chapter 9 ISSUANCE DATE 1
I z (commencing with Section 7000)of Division 3 of the Business and
a A - BLOG. ELECT. PLG. MECH.
H m Professions CMU ��Ryy license is in full f red ef_fat
z i m
Lice •Cha _ V I.ic.Nwnbe�OJJR((CC�},Nawz_ I p
o H Date Contrudor�6" o u ertino
a,y f BUILDING PERMIT �,*r
In w a OWNER-131DECLARATION '
U - INFORMATION
wa N I hereby affirm that I am exempt from the Contructcr's License MISC.- REFER TO ORD
H LL 0 j Law for the following reason.(Sec.7031.5,Businessund Professions PERMIT ISSUANCE 6.00
J VALUATION S/FT.
Code:Any city or county which requires a Permit to conswet,aIle"
2w,¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
o u requires the applicant for such permit to file a signed statement that L TOTAL
whe is licensed purwant to the provisions of the Contmetor's License PERMIT TO
HiQ Law(Chapter 9(commencing with Section 7000)Of Division 3ofthe
Business and Professions Code)or that he is exempt therefrom and GTY. PLUMBING PERMIT FEE 4---c-//
¢ H the basis for the alleged exentplion.Any violation of Section 703 L5 STORIES TYPE CONSTR.
o ; by any applicant for a pemtilobjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more thus five handled dollars($500).)
❑ 1,as ownerof the property,or lily employees Mill wugesa, BACK FLOW PROTECT. DEVICE 2.00
their sole copcntion,will do the work,and the structure is not OCG.GROUP RES.UNITS
mmru
inn aided or offered for IS (Scc. 7044, Business and Pi-Wessions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner oI'
property who builds or improves thereon,and who does such work F IXTURES-PER TRAP 4.00 50.FT FLOOR AREA TOTAL ACREAGE
40 himself or through his own employees,provided that such improve-
rents arenot 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- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or ice RES IND CON PB Omar
Prove for purpose orsale.L INDUSTRIAL WASTE INTER. 20.00
❑ 1,as owner of the property,am exclusively'contracting with
licensed contraemrs 10 construct the project(Sec.7044,Ruthless LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code: ]lie Contractor's License Law docs not apply
m an owner of Prol,crly who builds or improves thereon, aid will) LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contrums for such pruiccls will,a c,mractl)r,)lic'cnwd pursuant w
the Contractor's License Law, SEWER-SANITARY-STORM-EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,HAP.C.for this WATER HEATER W/VENT 4,00
reason
Date Owner WATER SYSTEM 4.00 ACC,DATE ACC.FILE NO.
W'ORKERS'CO.NI PENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-inure, ZONING ENG.SITE NO.
y or a certificate of Workers'Compensation Insurnmc o a certifwJ
�t copy Ihereof(Sec,380olict
Policy
No. LQ ❑ Cartif1w p 'She t FIRE SPR INK ENERGY TQA
❑ Ccrtifi' 'on divisioMISC. REFER TO ORD.Zp Applicant v C N ED Y � N�NCERTIFICATE 'ION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU 5: COMPENSATION NSURANCE PLG.CONTR. LIC.NO. PLG YE:]
❑ N� Y ❑ NEI
Z
(Phis section need not he completed if the Permit is for Ana TOTAL
hundred doll...IS 100)or Is.)
U O 1 certify that in the pertbmlance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner v,m In
O W become subject to the Workeri Compensation Laws of California.
Date-Applicant BUILDING
aALTER OR ADD TO MECH. 4.00
} m NOTICE TO APPLICANT': 11,after making this CeRifiealc al Ex-
? umption,you should I Icon c subject Io the Workeri Conl,aomion APPLIANCE 4.00 PLAN CHECK
provisions of the Lahor Code, you nem
st forthwilh comply with FEE
U such Provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10=C.F.NL) 3.00
CONSTRUCT ION LIiN'DING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency tot EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this Permit is issued(Sec. MICROFILM
3097.Civ.C.1. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50ELECTRIC6 .�G
Lender's Address
I certify that I have read thisupplieation and state that the ahose VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
Rdinanca .red state laws relating to building c ngnmtion, and BOILER-CO MPOH.Ror100,000B.T.U.) 4.00
hcrcby authorize rcpresemaiivcs of this city toonto upon the
f aWvrmm�lioncJ Property fir imlrcction purlwse, BOILER-COMP (Over 100,000 BTU)SEE FEESCH. MECHANICAL
(We) agree to save, indannify and kee harntlz the City of _ MISC.- REFER TO ORD.
Cupertino against Nabi"•a,ju gmen is and cxpca"'wbidl PERMIT ISSUANCE 3.00 CONST.TAX
may in any way ac vg ' w' y i consequence ul the
' grand O rs per rt MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
S ISO Appli o a Date
OFFICE COPY