18656 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 18656
ADDR 5 I/
I�/ BUILDING - ELECTRICAL-PLUMBING=MECHANICAL x
OWN R'S PLAN CHECK VALIDATION
""MF/]� Q; / .� ,1 TV. ELECTRIC PERMIT FEE
PHONE I/
CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
Q.vl. ua NO 'T'(`J
, LIGHTING FIXTURES 10.00/1.00
ONTRACTON'S JUN 1
/ /may PPLIANCES-RESIDENTIAL 4.00 /� 19q�
AQ/KESS ...rY /1, t„ -
P.
/(� PANELS 10.00 CII V A TE OF APPLIC TION"
ARCHITECT a/•/J�y�'AE PANELS (OVER 200 AMP) 20.00 PLAN'CH c F�En f// V P.C.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00
AR H. ErvG, SPECIALCIRCUIT
PERMIT VALIDATION
ADRESS SB
zIP EMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 ,P
C o LICENSED CONTRACTORS D17CLARATION ���j/ '
me U I hereby xff'irra that I:un licensed under provisions ol'Chapter 9 ISSUANCE DATE
y Q% (commencing with Section 7000)of Division 3 of the Business air BLDG. ELECT. I PLG. MECH.
r y z Professions Co and my license is in full fore an I eIT cl ,r4 O
z 0 w- Licenssyy.((''hqs Lic.Numbe N-fL_.
0 z r ° UatelsJJ' '-9' ContmctorLO/1(,(. f14QPQ_ALY-
T
E BUILDING PERMIT
M a w ¢ OWNER-BUILDER DECLARATION INFORMATION
O REFER TO ORD
E
3 LL I- I herehy uH om that I am exempt from the Contruetor'p License MISC.-
u04 Law lot tire the following reason.(Sec.7031.5,Business and Professions f PERMIT ISSUANCE 10.00 vawnnON S/FT.
� - 0 Code Any city orcounty which requires a permit to construct. lie', _
EE to ¢Q improve,demolish.or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
°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
F z i
Law(Chapter 9(commenciag with Section 7000)of Division 3 oftlue
- a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
r 0
the basis for the alleged exmnption.Any violation nl'Section 7031.$ 1 STORIES TYPE CONSTR.
5_: any applicant for a permit subjects the applicant to civil penalty ALTER-DRAIN -WATER (EA.) 5.00 of not Inoue than five hundred dollars(8500).1:
❑ 1,as owner of the property.or my employees with wages asggCK FLOW PROTECT.DEVICE 4.00 oec.GROUP REB.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,AREA,COND. 5.00
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 5.00 SQ FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve'
meats arc not intended o,oftemd for at,.If,Iwwevcr,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvcmcnt is sold within one year of completion,the owner . .) 2.00 BUILDING USE
GAS-EASYSTEM-OVER 4(EA
builder will have the burden of proving that he did not build or int- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
❑ 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.8. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor'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
contacts for such projects with it contvuctorls)licensed pursuant to
the C11runor's License Law, SEWER-SANITARY-STORM EA,200ft/10.00 TRACT NO. PARCEL NO.
❑ lam«,rcpt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dale WATER SYSTEM 5.00 ACG DATE ACC.FILE NO.
WORKERS'COMPEN'SATION UECLARA'r ION WATER TREATING EQUIP. 5.00
I hereby:dl'irm that I have a certificate of consent to sell'-insure. ZONING ENG.SITE NO.
or aceHiticau of Workers Conmcosation Insurance,or a curthicd
copy thereof(Set.3800,Lah.C.).
Policy No. Company
O ❑ Certirisd copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z Certilit d copy'. ;,filed w1th the city inspection division. MISC.- REFER TO ORD.
O Applicant yOQLLLLT.8/. Is
Y ❑ N❑ Y ❑ No
lr W C17R'ri EICATF.017 EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.C.
Lel > COMPFNWiON INSURANCE PLG.CONTR. LIC.No. PLG.
CL O This section need not he completed if thone permit is for oI TOTAL Y❑ N❑ Y ❑ NE]
Z bandied dollmx(SI00)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued, I shall not employ any person in any nnanner so as to
U become subject to the Workers'Compensation Laws of California. BUILDING
O w Date-Applicant
ALTER OR ADD TO MECH. 5.00
a
} m NOTICE 70 APPLICANT': If,after making this Certificate of Es-
F z_ emphon,you should become snbjed to the Workers'COmpel,sation APPLIANCE5.0 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions of this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10SMC.F.M.) 4.
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency lot EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Cfv.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00'
Lender's Name HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lenders Address
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county BOILER-CUMP13 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby amhorin representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL ��
above-mentioned property for inspection purposes,
(We) agree to save, indmanify and scup In,rn.less the City of MISC.- REFER TO ORD.
CONST.TAX
Cupertino .,.just liabilities,judgments, costs and expenses which .
may in ly ata acr ' ,qui a said City in consequence of the PERMIT ISSUANCE 10.00it
ranting thi anti MECH.CONT, LIC.NO. I MECH. /
TOTAL �-
nature< DConlru<lor Date
VV OFFICE COPY