C6106 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING , APPLICATION & PERMIT
ADDRESS 610 6
BUILDING -ELECTRICAL,-PLUMBING-MECHANICAL
OWNER'S LAN CHECK VALIDATION
NAM o(� OTV. ELECTRIC PERMIT FEE
1�-hC.)(1/x/�Cr'-L�` PHONEa53--13�1`f
•' CONTRACTORS /� l Q� UTLETS-SWITCHES-RECEP 5.00/1,00
NAME `Q• L4 L� 1 I 1
I�Up� ivYV SQ.hJL Ce3 LICNo. ILIGHTING FIXTURES 5.00/1.00
ADDRESS oe's (�u� C \ PPLIANCES-RESIDENTIAL 4.00
aoOREss ds'^ '"-S
-(�r'x CtA'�NA7 f PHONE OI I�-I-7..oyV PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHELK FEE P.C.NO.
OR
ENGINEER LIC.
c.No. SIGNS TRANS.
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 15.00
APPUGANr1 MOTORS SEE FEE SCH.
aoDREss �
SERVICE CHANGE
, 00 LICENS1iU COMI'RACI'ORS DECLARATION -
¢ u,t I herehy affirm that I am licensed under provisions of Chapter 0 ISSUANCE DATE
o,< N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F m z Professions Code,and my license is in full force J c aincpp11,,��1 -2-3 O El 110
te o w- License Class °I Lie.Number \'
o F w Date��/ Contractor
a u y 17f a BUILDING'PERMIT
¢ ¢w a OWNER-BUILDER DECLARATION -~--
MISC.- REI�E
TO ORD .INFORMATION
X
3 u H I hereby uflifm that I am exlrnpr from the Contractors License VALUATION 8/FT.
H LL o 4 Law him the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requiresa permit W cunstrud,alteq 2O improve,demolish,or repair any structure,prior rU its issuance,alsoELEC.LDNTR. LIC.NO. LEC. 1
O u requires the applicant for such Permit to file a signed statement that TOTAL PERMIT TO
A w m he is licensed pursuant to the provisions of the Contractor's License
Hsi Law(Chuptcr 9(commencingwith Section 7000)ofUivision3 ofthe
a Business and Professions Code)or that be is exempt therefrom and QTY. PLUMBING PERMIT FEE U�
IS H p the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
La -;m by any applicant fora Permit subjects the applicant toa civil penalty ALTER-DRAIN&VENT IEA.) 4.00
of not more than five hundred dollars(%500).):
❑ 1,as owner of the property,or my employees with wages as BACK 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,AR EA,COND. 4.00
Code:The Contractor's License Law does nor apply to an owner of
property who builds or improves thereon,and who docs such work F IXTUR ES-PER TRAP 4.00 SO.FT FLOOR AREA TOTAL ACREAGE
. himself or through his own employees,provided that such improve- GAS-EA.SVSTEM-11NC.40UTLETS 4.00
ments arc not intended or offered for sale If,however,the building
or Improve.naht 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. RE IND COry PB Omer
Prove for Purpose of salt.). _ INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSOHSPARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to in owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts I'orsuch projects witll a cont,acor(s)licensed persuum to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ I ani rsento under See ,B.&P.C.I...this WATER HEATER W/VENT 4.00
mason
Owncr Date WATER SYSTEM.EWATERTREATING
4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION EQUIP. 4.00
1 hereby alarm that I have a certificate ofConsent to self-insure, ZONING ENG.SITE NO.
or a certificate r f Workers'Compensation Imurance,or a certified
copy thcrcot(Sec.38 LaahC IJPolicy NOL$-f�L�sl( d� -C... iav-(�-
O ❑ CerOliedcopyhsluTchylionished) fIRESPRINK ENERGYTZa
Z Certilic�'YDpyis filed with }he City inspection division. REFER TO ORD. y ❑ N❑ Y ❑ N❑
Applicanl�L.{. Q
PERMIT ISSUANCE 6.00 PLooD zoNE A.L.0 c.
OC - CER'IIFICA'rfi OF iw- Pf10N FROM WORKERS'
COMM INSURANCF. PLG.CONTR. LIC.NO. PLc. ❑ ❑ ❑ ❑
d > TOTAL V N Y N
([his nccHOR nccd not be completed if the Permit is for one
Z handfed dollars(5100)or 1111.1 FEE SUMMARY. '
U O 1 ecrtit'y that in the performance of the work for w1befthis Per- OTY. MECHANICAL PERMIT FEE
LL F- mit is issued, 1 shall not employ any person in any mannerso as to
O w becammncsubject Atothe Worken'Compensation Laws Of California. BUILDING 5�,�
Dpplicant ALTER OR ADD TO MECH. 4.00
} N NOTICI'-TO APPLICANT: If,after making this Certificate of Ex 4.00 PLAN CHECK
f" Z emption,you should become subject to rhe Workers Compensation APPLIANCE
provisions of the Labor Code, you most forthwith comply with FEE
U such pfovisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10)MC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 10MC.F.M.) 5.00 SEISMIC FEE 50
I herehy affmn that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2,00 MICROFILM
3097.,CiCie.C.).
the oanec of the work I'or which this hermit is issued(Sec. HEATING UNIT(TO 100,000 B,T,U.) 4,00
v.
Lenders Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's AAdress
I ceNdy that I have rood thisapplicaHurt and state that the shove VENTILATION FAN (SINGLE) 3.00 PLUMBING
information n correct,I agree i g to b with nII oily and enemy BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
ordinances and slate laws relating to building Construction, and -
aherebybove- authorize ropertyforsins ec this city es cmcr PER. the BOILER-COMP IOver 100,000 BTU)SEE PEE SCH. MECHANICAL
above-mentioned property liter inspection purposes.
(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
ma in any way accrue against aid City in consequence of the
gr'h i0gr this permit. MECN.,CONT. LIC.NO. MECH.
31 TOTAL TOTAL 51.00)
Signet re of Pplicant/C ntractor al
OFFICE COPY