5618 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENT[FICATI ON PERMIT NUMBER
AUILDING APPLICATION & PERMIT
OGRESS
O 1#. ,tC! /Cp BUILDING - ELECTRICAL-PLUMBING-MECHANICAL5618
\ pWNEV1' T••7 ^ "4� T x >•'` ✓".', IN•. 1 . PLAN CVIE CK VALIDATION
"""'F N'1 Op DTY '•51s �fECECT4RIC PERMIT jtiFfE
I H.Y PHONE '.R, An''si.Af •.. r� -'"• d.:-T?X'.C�4t v." I43'+•Ly
cox RAcrORS 3 UTLETS-SWITCHES-RECEP 5.00/100 `j-cl
N ME /(
G&k (INs /� Ic.No 3`'�( / 3 LIGHTING FIXTURES 5.00/1.00 v
\/ F.ovTRAcrons C��B�It� PPLIANCES-RESIDENTIAL 4.00
RODRE55 C �o
/C N ANG PHONE 1/V /rQD 1/C PANELS 5.00 DATE OF APPLICATION
ARCHITECT 6-00 PLAN CHECK FEE P,C.NO.
DR SIGNS
ENGINEER SIGNS .00
LIC.NO. TRANS..
ARCH.OR ERG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. F7 r
ADRESRrs MOTORS SEE FEE SCH.
ADOREss
1
SERVICE CHANGE 0 JUL
woo LICENSED CONTRACTORS DECLARATION /s /s
¢r u I hereby affirm that I am licensed under provisions of Chapter 9 Cit D C ANCE DATE
Nam (commencing with Section 7000)of Division 3 ofthe tlusiness and BLD L �¢+ MELH.
H h i professions Codcr@_Yy license is in full for /`F f A l 77
❑ ❑ "j�-1 ❑
o w- Licenseslass JJ / Lic.Number���yL�7 IL�1J
j_9 $��Contractor 9AIINZAA
><¢¢
OWNER-BUILDER DECLARATION -S>,kINOiiNiA'(IL}N
[ ov° MISC.- REFER TO ORD -
0 w 1 hereby affirm that 1 am exempt from the Contractor's N License VALUATION E/FT.F
u.o a Law for the following mason.(Sec.703 1.5,Bu inasand Professions PERMIT ISSUANCE 6.00
Code Any city or county which requiresa permit loconstruct,alter,
i X Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
ti O u rcyuircs the applicant for such permit to file a signed stalemcnt That TOTAL/ 'O PERMIT TO
wm u, he is licensed pursuant to the provisions of the Contractor's License •�H K' .Ts - T'�
Fir Law(Chapter 9(commenemg with Section 7000)of Division 7 of th Y=-Yk }TU •14/k`� '�x'T=«i .A..fk x..S`: Asa }• P �-
Business and Professions Code or that he is exon 1 therefrom and OTkY r ' PLUMBING PERMIT ,'�$FEE' �r
fie ) p q:r 4 RXa♦ •sb' r� � '� •� 1'S
¢f p the basis for the alleged exemption.Any violation of Section 703 L5 �i..e eR•. -er.Y. �x�rt._ t.. t✓vIcfTf 14r u+n. STORIES TYPE CONSTR.
dgm be any applicant for a permit subjects the applicant tort civil penalALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than Five hundred dollars(5500).):
❑ 1,as owner of tmc property,sr 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 ar 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 theorem,and who does such work FIXTURES-PER TRAP 4.00 o-U sa.FT.FLOOR AREA TOTAL ACREAGE
T himself or through his own employees.provided that such improve. UTj
ments arc not intended or offered for Sala If,however,the budding GAS-EA.SYSTEM-1 I LETS 4.00 _
or improvement is sold within one year of completion,the owner. GAS-EASYSTEM-OVER 4 IEA.) 100 BUILDING USE
builder will have the harden of proving that h . .
e did not build or im- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WA$ NTC. 20.00
❑ I,as owner of the property,am exclusively contracting with D D D D
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 Contractor's License Law does not apply
1O an owner of properly who builds or improves thereon.and who LAWN SPRINKLE 1.00
contracts for such projects with a coutractor(st licensed pursuant m
SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the C'ontractor's License Law.
❑ lam exempt under Scc. .N.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPF-NSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that 1 have a certificate of consent to self-in tune ZONING ENG.SITE NO.
or[a' cer/tiRficate of Workers'Compensation Insurance,or a certified
i0W,1UQie,1-Y'RmpanNaA. -
0 ❑ Certifyie��ddQtop,' is hereby fuu�vrrnished.yrt yl�p FIRE SPRINK ENERGY T.24
Z Z ❑Icant�l(/!f/cordCQs fle6lL-.LO t. _yrP yijyp�{•m division. MISC.- REFER TO RD. Y D NO Y D ND
0 nnp uc��(-�`=
Cr CERTIFICATE:OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 - FLOOD ZONE A.L.U.C.
L >_ COMPENSATION INSURANCE PLG CONTR. LIC NO. PLG. N D Y D NEI
(L D (This seUoo lneed not be completed if the pernut Is for on TOTAL
O Z hundred dollars(5100)or less.) L •<y.� r wllsa to E..t �y v ey2� tTv 41�'[ax f L ° :} �jrw •'x' j"•`r`S+•ni
U O I certify that in the performance of the work for which this perJtl Ty.SF d y+ x../. i A �,i} .'FEE SU114IARY.a'C
l.L F mit Is Issued.1 shall not employ any person in any manner so as to +TA' ,y.'+ M Y,�H Imo.- 9; 4y. tr t - A�wAs
O w beLome subject m the W nrkers'Compensation Laws of Cabforma.
Uatc Applicant ALTER OR ADD TO MECH. 4.00 BUILDING fZl
} y NOTICE TO APPLICANT: If after making this Certificate 0(Ex-
F" Z emption,you should become subject to the Worker:Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provision or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10,000GF.M.) 3.00
CONSTRUCTION LIiNDINC.AGENCY AIR HANDLING UN O.00D C.EM.) 5.00 SEISMIC FEE vJ V
I hereby affirm that there is a construction lending agency for EXHAUST HOOD WITH DUCT) 2.00 `
the performance of Ore work for which this permit is issued(Sec. MICROFILM
3097,Civ.C). HEATING UN (TOE .U.) 4.00
Lender's Name HEATI NGU V ER 100,000 B.T.U.)Z50 ELECTRIC
Lender's Address
1 certify that I have read this application and state that the above VENTILATIO FAN 3.00 61.information is come(. I agree to comply with all city and county PLUMBING
• pl ordinances and state laws relating to building convmnion, and BOILER-GlOfuP .P.or 10 ,000 B.T.U.1 4.00
"" hereby authorize representatives of this City to enter upon the BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL S-e2
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep herrnless the City of MISC.- REFER TO ORD.
Cupertino against liabilities, judgments, costs and expenses which PERMIT ISSUA CE 3.00 s� CONST.TAX
teeter,in . way aeeruagainst said City in consequence of the
got ingo is pe 1. MECVI.CON T. LIC.NO. TOTAL� SZ'1•cw_- 7'T•�� , � � tcasTOTAL�_ ; l '
'S mature of Applicant/Ci tractor Dale
OFFICE CO