0452 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI- POINT PEPJONLY
BUILDING PROJECT IDENTIFICATION - . PERMIT NUMBER
BUILDING spy APPLICATION & PERMIT 0452
ADDRESS
.-{/- ea BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNaS b I "'a __
. -�' - r 4 'I - -- ,, PLANCHECK VALIDATION
1NNAA,ME 1, yt OTYA."" J t' ELECTRICPERMIT '� " 'FEE
/,Q �Rgmwr/ PHONE a '.I - -,
rCONTAME °SQL RQQ UTLETS-SWITCHES-RECEP 5.00/1,00
IKC LIC.NO LIGHTING FIXTURES 5.00/1.00
ONTAA ORs •.��'• PPLIANCES-RESIDENTIAL 4.00
AGONIES qif'C 21
(NONE f 2 PANELS 5.00 DATE OF APPLICATION
PRCNITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER SIGNS TRANS, s 3.00
LIC.NO PERMIT VALIDATION
ARCH.OR ENG, SPECIAL CIRCUIT 5.00
ADDRESS
zlP TEMP.METER OR Irs. 15.00
APPLICANTS MOTORSEE SCR.
ADDRESS
SERVICE CHANGE - 10,00 [Y
w or o LICENSED CONTRACTORS DECLARATION
u u I hereby affirm that I am licensed under provisions of Chapter 9 ____FI SSUANCE DATE
w< w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r Professions Code. nd my license is in full for a off t ❑ ❑
z O v, -. Licen Class Li..Number
g Y Date Contractor
`�f'BUILDING PERMITs•
ac ¢¢ OWNER-BUILDER DECLARATION ':•''" t
a,D ;,:;` ,I-�.JINF.ORMATION;:Iy'E�.a:
`i ; a.a 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
'II u o¢ Law for the following reason.(Sec.7031.5,Business and Professions VALUATION S/FT.'
F y w J PERMIT ISSUANCE 6.00
> Code:Any city Or county which structure permit tDconstruct,a aU, ELEC.CONTR. LIG NO.
¢o improve,demolish,or repair any structure,prior to its issuance,also ELEC. '
- O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
A mm_ he is licensed pursuant to the provisions of the Contractor's License �p��
r z i Law(Chapter 9(commencing with Section 7000)of Division of the "' `AZje -IYtr "'I't'raI" A.s yfaf -`yH
4 c Business and Professions Code)or that he is exempt therefrom and DTV,. 3 -'Qep I PLUMBING PERMIT - F ; F.E,E.J,q
¢ r $ the basic for the alleged exemption.Any violation of Section 7031.5 ..1;:1°a vLO `:I.vr.v'v'I/ 'S .+t -�1'" +c• "7A+'-•I^^t STORIES TYPE CONSTR.
pg by any applicant for a permit subjects the applicant toacivilpenslty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars($500).1:
❑ I,as owner of the Property,or my employees with wages asBACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure Is not
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM•11NC.40UTLETS 4.00
mems are not intended or offered for sale.If,however.the building
owne owner-
builder
lder will have
is Sold within one year of completion,the owner• GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Om.,
prove for purport of sale.). INDUSTRIAL WASTE INTER. 20.00
❑licensed1.as owner of the property,am projecexclusively Se contracting with ❑ ❑ ❑
a 13
dPrcontractors to .Contra the project(Sec.7044,Business LAWN SPRINKLERS•1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The who
o License Law does not apply
to an owner of properly who builds or improves(hereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/8.00TRACTNO. PARCEL NO.
the Contractor's License Law.
❑ I am exempt under See...B..&P.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FICENO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a Cerlificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof($ep.�3,�00,Lab.C.ly.
PGIicY Na Company' �i
Q ❑ Certified copy is hereby famished. FIRE SPRINK ENERGY TZi
Z Z ❑ Certified cop is fi w't th c' inspection division. MISC. REFER TO ORD. y N❑ v ❑ N�
p Applicant 4Z,a_ (.y- '
� = CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LJJ > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
Q. G TOTAL Y❑ N❑ Y❑ N❑
(This section need not be completed if the permit is for one
Z .hundred dollars(5100)orless.) l .¢GI',rt -! y .. rdr'4Y, ",Sai`Y+r T $y-=- ns'?,
U O• I certify that in the performance of the work for which this per DTV. MECHANICAL�PERMIT. ` 4 L<.FEE t-KVi4�4M.EE SUMMARY N v;';�,.,,J,
ly FF mit is issued,I shall not employ any person in any manner so as to ,,TY`N„'+*M 5 r Q ys-,v f, kn.",v,w f,I?*..rv.i.' �+ I,JE .iti t',%i
0 tu becomesubject to the WGrkeri Compensation Laws of Califamla. BUILDINGJZ,SD
Date Applicant ALTER OR ADD TO MECH. 4.00
} in NOTICE TO APPLICANT: If,after making this Certificate of Ex-
emption.you should become subject to the Workers'Compensation JAPPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you mus[ forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=r-F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10A00C.F.M.) 5.00 SEISMIC FEE
I 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(See. PO
UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,CN.C.). -
Lender'sName UNIT(OVER 100,000 B,T,U,17.50 ELECTRIC
'
Lender's Address
I certify that I have read this application and state that the above ION FAN (SINGLE) 3A0
. information is correct. I agree tG comply with all city and county MP(3 H.P,or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and slate laws relating to building construction, and
hereby authorize representatives of this City to enter upon the OMP(Over t00,DO08TUISEEFEESCH, MECHANICAL
above-mentioned property for inspection purposes.
(We) agree 10 save, Indemnify and keep harmless the City of 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 SSUANCE 3.00
gra ting/aJf lhl9 p IL �/� @r MECH. LIC.NO. MECH. y; /•F./�I�IIXf��� p� TOTAL ;�/,,, y /
T",Of �f �0
�Raalure Of Applicant L'ontmctor DatCof Applicant Contractor Date ;a:.ir.`-.`+,,.,v.=..rF-
OFFIC�COPY