6148 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDING PROJECT 1 DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADOn Ess BUILDING - ELECTRICAL-PLUMBING-MECHANICAL flim 6148
Owry ER'S PLAN CHECK VALIDATION
7 N"1E QTY. ELECTRIC PERMIT FEE
ONE
CONTRACTORS 00
NAME UTLETS-SWITCHES-RECE . .
% L.c.NO. LIGHTING FIXTURES 5.00/1.00
ACTOR's
ADDRESS PPLIANCES-RESIDENTIAL 4.00
ADDRESS e la, �y
PNONEZ �Qlp PANELS S.00 DATE OF APPLICATION
ARCHITECT A"
ENGINEER
SIGNS 6.00 PLAN CNECK FEE P.C.NO.
OR Y
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. - SPECIAL CIRCUIT S.00 PERMIT VALIDATION
ADDRESS
zlv EMP.METER OR POLE INS. 15.00 �D1
APPLICANT MOTORS SEE FEE SCR.
ADDRESS
SERVICE CHANGE 10.00
'02 LICENSED CON'T'RACTORS DECLARATIONA Is
, u U hereby affirm that I am licensed under provisions of Chapter 9 I ISSUANCE DATE
vii< 'A (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F y z Professions Cede,and r y license is in full force and a yt (�''J -�
z: O w - License Class Lic.Number ,j 11 �L-Z ❑ ❑ ❑
Qx Dale_/.G �Conlractorp
¢ ¢ ¢ OWNIi BUILDF-R DECLARATION VCL BUILDING,PERMI�T�:.,{ -�
¢ e Z INFORINi,1T10Nari;:b•_i
U REFER TO ORD
w 3 0 r I hereby affirm that I am exempt from the Contndor's License MISC.- VALUATION S/FT.
F .. Oj Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00 VATION
Code_Any city or county which requires a permit to constrUCL ahem _"6w
ae Q Q 0 Improve,demolish,Or repair any'straclurc,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O¢ requires the applicant for such permit to file a signed statement that TOTAL tbTbR
IT TO
a w m u he is licensed pursuant to the provisions of the Contractor's License
71
F z a Law(Chapter'J(commencing with Section 7000)..f Division 3 ofthe
Business and Professions Code)or that he is exempt Owrel'rom and CITY. PLUMBING PERMIT FEE
at =$ the basis for the alleged exemption.Any violation of5ection 7031.5
TYPE CONSTR.
by any'applicant for a permit subjects the applicant ma civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00of not more than five hundred dollars(S500).):❑ 1,as owner of mC property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 I a)s5^ NITS
their role compensation,will do the work,and the structure Is not d1
intended or offered for Sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 4.00
Code:The Contractor's License Law docs not apply to an owner of
property who build or improves their...,send who docs sods work FIXTURES-PER TRAP 4.00 so. T.FLO AREA TOTAL ACREAGE
• himself or through his own employees.provided that such improve-
menus are nut intended or offered for sale.if,however,the building GAS-EA.SYSTEM-11 NC.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 ino ES IN CON PB Olner
prove for purpose of sale.). I N DUSTR 1 A L WASTE INTER. 20.00
❑ I,as owner ol'the properly,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ..ewa095 PARCEL NO.
send Professions Cude:'Ihe Contr.¢tor'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,cit projects with a contrachms)licensed pursuant to i
SEWER
the Contractor's License Law. -SANITARY-STORM EA.200ft/g.00 TRACT NO. PARCEL NO.
❑ lam exempt under Scc. .B.&P.C.ti+r this WATER HEATER W/VENT 4.00
rea,nl
Owner pp �1[[eC// I Date WATER SYSTEM 4.00 ACC.DATE ACC.FILENO.
W/w1�JRC Vc 4 3 TION DECLARATION WATER TREATING EQUIP, 4.00
I hereby at firm that I have a certificate of consent to self-insom' ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
c py thereof ISec.3800,Lab.C.l. `i`�"FGItT-r�n
P y No-• Company
O �Cerlifird copy is hereby lumishcd. FIE ENERGY L]4
Z 2 o CertifieJ copy i thea with the city i3paction J...siom MISC. REFER TO ORD.
O APplic:mt �0 y Y ❑ N❑
� N CER-1 ICA'fli Olr EXEMPTION FROM w KIiRS' PERMIT ISSUANCE 6.00 FLA.L.u.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.No. PLO.
CL ('Phis SB 666 need not he completed if the permit is 1'or one TOTAL V y❑ N❑
hundred dollars IS 100)or less.)
U O 1 certify'that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY+
EL H mit is issued,I shall not employ any person in any mannerso as to
Ow hecnmc subject to the Workers Compersation Laws of California. BUILDING
Date Applicant ALTER OR ADD TO MECH. 4.00
} ran NOTICE TO APPLICANT: If,after making this Certificate of -x.
F_ Z emption,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 UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGI7NCY AIR HANDLING UNIT(OVER I0=C.F.M,15.00 SEISMIC FEE
I hmeby ult'ina that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of lire work lir which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. 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 1 have read this application and state that Ibe above VENTILATION FAN (SINGLE) 3.00
• i^formation is correct. 1 agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby .01hurire rcprescrrmives of this City to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCR. MECHANICAL
abovementioned property for,inspection purposes.
(we) agree to sive, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments costs and expenses which CONST.TAX
may is any way accrue against said ity in our ..,cL of the PERMIT ISSUANCE 3.00
of this peunit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signam AVVhcanU on acro Date
OFFICE COPY