4586 (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 I► [Q [`
ADDRESS `�J U U
ia3 y "T�K�! L� BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S PLAN CHECK VALIDATION
""M DTV. ELECTRIC PERMIT FEE
�� h�i •/
PHONE
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CONTRACTORS UTLETS-SWITCHES-RECEP 5.00/1.00
NAME
iy4! /� LIC.No. 7 LIGHTING FIXTURES 5.00/1.00
CONTRACTORs / APPLIANCES-RES
4.00
ADDRESS �Q'y"
y - PHONE z'12- /may PANELS 5-00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLANCHECKFEE T P.GNO.
OR
ENGINEER
TIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG, SPECIAL CIRCUIT S.QQ PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
A DURESS
SERVICE CHANGE 10.00
w o o LICENSED CONTRACfORS DECLARATION /Q3
v U I hereby affirm Ilial I am licensed coder pmvisimis of Chapter 9 ISSUANCE DATE
w G m loot mencing with Section 7000)of Division 3 of the Ihoinesu vnrl BLDG. ELECT. PLG. MECH.
D z Professions Code, yid m 'cense is in full force and vif i . ❑ ❑ ❑ ❑
z: O m- License Class Lic.Number 2- /Y
O v, r w Date Comractor // O �Z
a Y s d / BUILDING PERMIT
¢ w a OWNER-BUILIMP DLCLARA'1'ION INFORMATION
t'xu ; y I hereby affirm that I am exempt from the Contractor s
License MISC.-
REFER TO ORD
u04 Law for the following reason.(Sce.7031.5,Bosinessand Professions PERMIT ISSUANCE 6.00 VALUATION $/FT.
r - Code:Anycity orcounly which requires a permit to construct.alter. NN
as o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.rv0. _LEC. V
ca
-0 u requires the vpplemit for such permit to file a vigned shtenent that TDTA P PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractors License
F z
as
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
ss Business and Professions Code)or that he is exempt therefrom and DTY. PWMBING PERMIT F
¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 U RIES TYPE CONSTR.
a - by any applicant for a permit subjects the applicant toacivil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
of not more than five hundred dollars(S500f);
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.G90uP RES.UNITS
their sole compensation,will do the work,and the structure is not CY /�
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 J-- AA 7 J
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
himselforthrough his ownemployees.provided however,the
improve
ments ton not ommen his arofferecl for employees.provided
that such
building GAS-EA.SYSTEM-11NC.4OUTLETS 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[lint ha did not build or I'll- RES IND CON PB CO.,
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
0 1,as owner of the Properly am exclusively contracting with
licensed contractors to construct the project ISec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:T'he Contmnoi s License Law does not apply
to an owner of property who builds or improves thereon,and whn LAWN SPRINKLERS-OVER 5 (EA.) -1.00
contracts for such projects with a eontmetots)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT No. PARCEL NO,
❑ 1 am exempt under S".-.B&P.C.for this WATER HEATER W/VENT 4.00
neesnn
Date owner WATER SYSTEM 4.00 ace.DATE ACC.FILE NO.
WORKERS'COIsIPENSA'1'ION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that 1 have a certificate ofemnscnt to self-insure, ZONING ENG.SITE N0.
or a cert ifeate of Workers Compensation IO(llra0C4 nr a cerliLrd
copy thereof(Ser.3800,Lab.C.). J+---�-�
Policy No. Company
O 0 Certifiedcopy'isherebyfurmshed. FIRE SPRINK ENERGY T-24
Z Z AY.CeHbit:�co y_i filed -t I it 'i�nspeciion division. MISC.- REFER TO ORD. y � N� y � No
F O mli g
� T CERTIFICATE OP EXESIPT10N FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.uc.
LU 1 COMPENSATION INSURANCE r PLG.CONTE. LIC.NO. PLG. y NE] l v N
IL 0 (This section need nut be completed if the print, is for one TOTAL
Z hundred dollars is100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
ly H mit is issued.I shall not employ any person in any manner so as to
U becoMIM
e su c the Workers'�,ptnpenr,�7on L sof a ilonua.
W Dam y npplicaut L' 7Y- C '�'�' BUILDING
d ALTER OR ADD TO MECH. 4.00 _
} m NOTICE 'IU APPLICANT: IL,at ter making this Certificate of Ex-
F, Z emption,you should become subject to the Workers'Cmnpensatioi 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 10MC.F.M.) 3.00
CONs'fROcnON LENDING AGENCY AIR HANDLING UNIT(OVER 1000C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that ,here is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). 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
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
informalun i5 correct. I agree to comply with all city and county BOILER-COMP13 H.P,or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relc
ating to building c ,tructooa. and
hereby Bmhori, representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTUISEE FEESCH. MECHANICAL
above-mentioned property for 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
may in ay way accrue against said City in cansey urnrr if the
grants goI tins nn, x MECH.CONT. LIC.NO. MEETAL
-� rrF ii 71.3 TOTAL rS^7
Signature fit Applicant/Contractor D' r
OFFICE COPY