6564 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATIONPERMIT NUMBER
ADDRESS
c APPLICATIONS& PERMIT
/O fb /Y/,• Ile�/i BUILDING- ELECTRICAL-PLUMBING-MECHANICAL 6564
OWNER'S - PLAN CHECK VALIDATION
N E
1q^M n, L UTY'.: ELECTRIC PERMIT FEE
Y • /�d/'Q PHONE
CONTERACTOR$ UTLETS-SWITCHES-RECEP 5.00/1.00
A
L ` LIGHTING FIXTURES 5.00/1.00 '
CONTRACTOR'S Fg PPLIANCES-RESIDENTIAL' 4.00
ADDRESS
Pyo ifR QiL PHONE L PANELS 5.00 DATE OF APPLICATION
ARRCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LOC.NO. SIGNS TRANS. 3.00
ADDRESS ENa. SPECIAL CIRCUIT ,5,00 PERMIT VALIDATION
nv ITEMP.METER OR POLE INS. 15.00 ,
ADDRESNTE MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
O 0 2 LICENSED CONTRACTORS DECLARATION _ f0 G`f
<u I hereby affirm that I am licensed under provisions of Chapter 9 In A I SSUANCE DATE
w "' (commencin with Section 7000)of Division 3 of the Business and
¢H S B ELECT. PLG. MECH.
F z Professions Code A y ' ense is in full force y."d efNC1 ❑ ❑
z o,'^iI- License Class Lie.Number Y / Ai-
m r w Contractor
ids ///A( I�� �3 + 8�• �- I 1
¢ as Y G'��/� J BUILDING PERMIT-
Eat a OWNER-BUILDER DECLARATION
o s v INFORMATION.
W ; N 1 hereby affirm that I am exempt from the Contractor's License IMISC.— REFER TO ORD
F w /
tU
0 a law for the following reason.(Sec.703 1.5,Business and Professions PERMIT ISSUANCE 6.001 � N S/FT.
,Ai Code:Any cityorcounty which requires a permit to construct.after.
re ¢ ¢o improve,demolish,or repair any structure,prior to its issuance,also EIEC.GONER. LIC.NO. ELEC.
DLL requires the applicant for such permit to file a signed statement that TOTAL -
a. wPERMIT TO
$ he is licensed pursuant to the provisions of the Contractor's License �1
Fz >w Law.(Chapter 9(commencing with Section 7000)of Division 3 ofthe C'R067— }P_
- ¢ Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
fX Is 0 the basis for the alleged exemption.Any violation Of Section 7031.5 STORIES TYPE CONSTR.
i 3 by any applicant for a permit subjects the applicant to acivil penaltyM e7 - #4
o(not more than five hundred dollars(55001.): ALTER-DRAIN&VENT-WATER (EA.) 4.00
❑ I,as owner of the property,or my employees with wages asBACK FLOW PROTECTDEVICE 2.00 OCC.AGROUP RES.UNITS
their sole compensation,will do the work,and the structure is not .
intended or offered for sale (See. 7044, Business and ProfessionsDRAINS-FLOOR,ROOF,AREA,COAD. 4.00
Code:The Contractors 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
neents are not intended
ownemployees,for sale.
If,ho ever,(hat h improve- GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
mems are not intended or offered for sale.If,however,the building
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 that he did not build or im- RES IND ION PB Omer
prove for purpose ofsale.). INDUSTRIAL WASTE INTER, 20.00 1:1 ❑ 1:1 1:1 ID
1,as owner of the property,um exclusively contracting with
licensed contractors to construct the project(Sea 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
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1,00
contracts for such projects with o contractors)licensed pursuant to
the Contractor's License Low. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
„ ❑ hunt exempt under Soc. ,B.&P.C.I'nr this WATER HEATER W/VENT 4.00
reason
Owner Date - - WATER SYSTEM 4.00 ACC.DATE ACC,FILE NO.
WORK IiRS'COMPIiNSA'I'ION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent In self-insure, "ZONING ENG.SITE NO,
or o certificale of Workers'Compensation Insurance,or a certified
copy thereof(Sec. 00,LLuab.CJy
.
Policy arc Cony -f—
O Verified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z II✓Cerlified py Ia d w the y 5npection division.
O Applicant e �-� MISC- REFER TO ORD. Y❑ N Y No
cc: r2 CER'1'11'ICATIi OITI:XI:MPI'ION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOOZONE - A.L.U.C.
Lu >. (70MI4ENSA'1'ION INSURANCE PLG.GONER. ❑C.NO. PLG.
d 0 ('Phis section need not be completed if life Permit is for one TOTAL Y❑ N❑ Y ❑ N❑
0 Z hundred dollars IS 100)or less.)
U 0 1 certify that in the performance of the work for which this Per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner So as l0
OW h'earn syh) Io.Ilia Workers'C pensxti a L' s of 1111 nia.
D, )are_L'/!_F P Applicant_ "e�C'-.____ ALTER OR ADD TO MECH. 4.00 BUILDING SDI
} to NOTICE:T A PLICAN'1': I .a Icr making this Certificate of E..
F ? 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
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,DOOC.F.M.) 3.00
CONSTRUCTION LANDING AGENCY AIR HANDLING UNIT(OVER 10=1 F.M.).5.00 SEISMIC FEE
l.hereby affirm Ihal there 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.17.50
Lender's Address ELECTRIC
I certify that l have read this applical ion and state that the above VENTILATION FAN (SINGLE) 3.00
• information is correct. I agree to Comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless ilia City of MISC.,- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the 'PERMIT ISSUANCE 3.00
gra�n t{{ng of this ermil. MECH.CONT. LIC.NO. MECH, l�
El =_".et�`s ��r�� TOTAL TOTAL S� o
l� ti
Signature of Applicant�Contractor Da.q J—
OFFICECOPY