C 7264 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
8111 LDI NG PROJECT 1 DENTI FICATION PERMIT NUMBER
6UILDING ,f APPLICATION & PERMIT
\
ADDRESS 7 2 6 4
BUILDING- ELECTRICAL-PLUMBING -MECHANICAL
OwNER'S 'rV F '9� Y✓} { .Ftp �?;y^�-"amt ` '- PLAN CHECK VALIDATION
Is
NAMES}eve zjs)�-eJ3[t9 nTr;r °7 'BLECTRtCPERMITR� ? FE n, T-e f T
Z U ✓:C PRDxE J/ 1 ' 1 LJ L
CONTRACTORS
NAME UTLETS-SWITCHES-RECEP 5.00/1.00 �f G
5+&.✓e- Z Gn J<j� uc.ND,L1142.1 fog- LIGHTING FIXTURES 5.00/1.00 �� i //jKr
CONTRACTOR oxs PP LI ANC ES-RESIDENTIAL 4.00
ONTRACRE . �1
,z-, 2-q [-1yG
y Z '- f✓ PHONE zSM3z9 PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC,No. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00 /
AEMOTORS SEE FEE SCH. 1
ADDRDDRESSSS
SERVICE CHANGE pA 10.00 7/J
ia o o
LICENSED CONTRACTORS DECLARATION
a U v I hereby affirm that I am licensed under provisions of Chapter 9 11 - I55 GATE
N a mw (commencing with Section 7000)of Division 3 of the Business and BLD EL PLG. MECH.
F m z Professions Code.W my license is in Or
11 force n eff�gs-17 ❑ ❑.�
Z 0 u, - License Class Lic.Numbe'45-A
L
o w 1- Dale Con lncmr - ci;E --Z,-Orkt s C'IPl 01 p09fi1(10 :-
¢ m ce 4 OWNER-BUILDER DECLARATION �- IL
w ;n m I hereby atflrm that I am exempt from the Contractor's License MISC.- REFER TO ORD ly;" INFORMATION
u, al o¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE VALUATION S/FT.
F v'0 Code:Any city or county which requires a permitto construct.alter, 6'�
¢ e ¢0 improve.demolish,or repair any structure,prior to its issuance,also EIEC.CONTR. LIC.N0. ELEC.
w0 u requires the applicant for such permit to file a signed statement that TOTAL C� PERMIT TO
8 he is licensed pursuant to the provisions of the Contractor's License
w. i Law(Chapter 9(commencing with Section 7000)of Division 3 of the ek rr jypyvy,ya �,''' Axl ;^e 'fs4; y+, e /
3 i c Business and Professions Code)or that he is exempt therefrom and QTY.$;} s, PLUMBINO:PERINIT ,�Lxa F
¢ H $ the basis for the alleged exemption.Any violation of Section 7031 5a. ) y,-,.a ,F '•, s.�n ^. «• STORIES TYPE CONSTR.
a3 by any applicantfor a permit subject the applicant toecivil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than live hundred dollars 155001.1:
❑ h as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 2.00 C.GROUP RES.UNITS
the it sole compensation,will do the work,and the structure is not
intended or offered for sale (Si 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 /
Code:The Contractor's License Law don not apply to an owner of ...)
• property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SD.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve. 30 4;;
/ments are not intended or offered for sale.If,however.the building GAS-EA.SYSTEM-l1NC.40UTLETS 4.00
or improvement is Sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1,00 BUILDING USE
builder will have the burden of proving that he did not build or
im- RES IND CON Pe Omer
.
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 2000
❑ L as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project ISec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.G0 ASSESSORS PARCEL NO.
an J Professions Code:The Contractor i License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1,00contra �l /
the Contractor's
ctor'sor hcensets Lwith aconlmcloHsl licensed pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCELING
-
0 Contractor's License Law.
❑ lam exempt under Sec.-,B&P.C.I'or this WATER HEATER W/VENT 4,00
nwson
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK E:RS'COM PE.NSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate ofconsent to self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,orra certified
yf�(theo f Sec.3500.LabC
ny-- "n4
L�0 A.jxN ri Company B.7
O ertified,copy is hereby(arith the
FIRE$PRINK ENERGY T]a
Z 2 CertifieJ c Ii1ed with the city tion division. MISC.- REFER TO ORD.
O Applicant v ❑ AN v ❑ IN
CCN CF-RTI F KATE OF E. ION FROM WORK ERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE. PLG.CONTR. LIC.N0, PLG.
C O ((his section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ ON F1
D Z hundred dollarS(S 100)or less.) iF A �., Jr-ss -
U O I certify that in the performance of the work for which this per-
1,,QTY: a.L MExCNANICA��FlRMIT FQH >t P86 WMMARY
LL F HIR is'slued I shall not employ any person in any manner so as to SLA s-^ <s *.,P" ^M " '+ lxt 1v1',.
U W become subject to the Workers Com enation Laws of California -
y Umc Applmant p ALTER OR ADD TO MECH. 4.00 BUILDING
} W NOTICE. TO APPLICANT: If,after making this Certificate of Ex-
F Z emption,you should become suBject to the-Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10p000.F.M,) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,OMC.FM.) 5.DO SEISMIC FEE i0
I hereby affirm that there is A construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(See. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address
ss HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
• 1 certify Ilia,I have read thisapplieation and state that the above VENTILATION FAN (SINGLE) 3.00
mtormation is correct. I agree to comply with all city and county, PLUMBING
ordinances and state laws relating to building construction, and BOILER-ODIaP(3H.P.or100,000B.T.U.) 4.00
hereby authorize representatives of this city to enter upnn the BID 8 COMP (Over tO0,DD0 BTU)SEE FEE$CH. MECHANICAL
shove-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 ova
may in any way accrue against said City in consequence of the
granting of this permit. MECH.CONT. LIC.NO. MECH. ;'�5,, r► p.:yE;,
_I
- 8 d' TOTAL
,{ SiBis naNre of Appl' ontraclor Date
'� OFFICE COPY