4201 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
�.
APPLICATION & PERMIT
BUILDING _ 4201
ADDRESS 16114-
3II\LCR LaG[� BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
R'S -'"�' --I R \ , 1 rt �Of k , T.a1y PLAN CHECK VALIDATION
OWNE
CITY. ELECTRIC PERMIT?}. �i tFEE.;
NAME""0T0P5 OUTLETS-SWITCHES-RECEP 5.00/1.00
LIC NO. LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S APPLIANCES
PHONE
4.00
ADDR ESS
PHONE PANELS 5.00 DATE OF APPLICATION
ARRCHITECT SIGNS 6.00 PLAN CHECK FEEP.C.NO.
ENGINEER
LOC.NO. SIGNS TRANS. 3.00
ADDRRESS ENG. 5.00 CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
AMOTORS SEE FEE SCH.
AOOREEE ORE$$
SERVICE CHANGE 10.00
f/ El
/f3
Doo LICENSED CONTRACTORS DECLARATION (/
<u u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w Z w Icommencin with Section 7000)of Division 3 of the Business and
a N BLDG. ELECT. PLG. MECH.
r w 2 Professions Code,and my license is in full force and effect. ❑ ❑ ❑
i o m - License Class Lir.Number
Z�w Dale Contrac[Or
a x Dm f 'g-BUILDING PERMIT.
MM OWNER-BUILDER DECLARATION _-1'�'f y�,'INF,ORMAT_ION' xJ I',y
wH 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
a .m j Law for the following reason.(Sec.703 Busineuand Professions pERM1T ISSUANCE VALUATION S/FT.'
us Code:Any city or county which requiresa permit toconstruct,alter, fi.00
ELEC.CONTR. LIC.NO. L�f�JJ V
e a a o improve.demolish,or repair any structure,prior[o its issuance,also ELEC.
' wD u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
$ he is licensed pursuant to the provisions of the Contractor's License
F r Law(Chapter 9(commencing with Section 7000)of Division3 at the F% + ,, qK,2 I Iw. "f,1Ls x' T
ic Business and Professions Code)or that he isexempt therefrom and QTLY. �*'"nA T'"'PLUMBING PERMIT j '.�`A 4,1
M H the basis for the alleged exemption.Any violation of Section 7031 5 M` t ,»5_...r'S �+Til.'Ga 'r1)c .a,.nvx S. ,sd$*'_ STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN (EA.) t
of not more than five hundred dollars 15500).): I Cupertino
❑ 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole comppenation,will do the work,and the Stmeture is not
intended Or a feted 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 re through his own employees,provided that such improve.
men[sare not through
onIanpldforsale.ILed that such
building GAS-EA.SYSTEM-1INC.4OUTLETS 4.00
or improvement is sold within one yen 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-
provefor purpose ofsale.). NDUSTRIAL WASTE INTER. 20.00 RES IND CON pe Om.r
❑ I,as owner of the property,am exclusively contracting with I ❑ ❑ ❑ ❑ ❑
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 Contractors 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 such projects with a contractods)licensed pursuant to SEWER-SANITARY-STORM EA.200it/5.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ I tempt under Sec. ,114P.C.for this WATER HEATER W/VENT 4.00
eason
Dau V -A 4-Os 1a.-. rnvRer WATER SYSTEM 4.00 ACC,DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 4.00
1 hereby affirm that I have a certificau of consent ro self-insure. ZONING
or a certificate of Workers'Compensation Insurance.or a certified ENG.SITE NO.
copy thereof(Sea 3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is fled with the city inspection division. MISC.- REFER TO ORD.
O Applicant •- Y ❑ N❑ v C] NE]
� y CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO, vLG.
da TOTAL Y❑ N❑ Y❑ N❑
LD Z (This dollars
need not be completed if the permit is for one
hundred dollars 151001 pe less.(
U O I certify that in the performance of the work I'or whish this per. QTY. s,MECHANICAL PERMIT .FEE" ,x r. `'FEE SUMMARY� f�;',;
Iy 1mit is issued.I shall not employ any person in any manner so as to
O w become subject to the Workers'Compensation Laws of California. O-
y Date Applicant BUILDING �O
} N NOTICE TO APPLICANT: IL after making this Certificate of Ex- ALTER OR ADD TO MECH. ` 4.00
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 V
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.NL) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10000C.FM.) 5.00 SEISMIC FEE Ste.
I hereby affirm that there is a construction lending agency 1'or EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name H EATING UNIT(OVER 100,000 B.T.U.)7.50
Lenders Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information n correct I agree tcomply with all city and county
or -PLUMBING
ordinances and state laws relating to building construction, and BOILER-COktR 13 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(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
yranking ofthispermit. _ MECH,CONT. LIC. MECH. (^�o-v.," t
1f1. ti-l/l r:..,-,an>P.°dY,
TOTAL „y
SlNwture of Applicant/Contractor Date >'. /7 �
OFFICE COPY