5449 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
;gpDING _ APPLICATION & PERMIT Wdi,k.r I rT_ BUILDING—ELECTRICAL—PLUMBING—MECHANICAL 5449
ONER'$
NAME - PLAN CHECK VALIDATION
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CONTRgCTOR 5
UTLETS-SWITCHES-RECEP 5.00/1.00
'' �f. �'- uC.so '1 LIGHTING FIXTURES 5,00/1,00
,-_ f.ONTHACTOR 5
ADDRESS // y I/J t'i+/ _ PPLIANCES-RESIDENTIAL 4.00
��C r /,f. /,/if :�..f (..:0/ PHONdt/fJ'sSJ PANELS 5.00
An LRI SCT DATE OF APPLICATION
ENGINEER - - SIGNS B PLAN CHECK FEE P.C.NO.
! LIC.NO. SIGNS TRANS. 3,00
gflCN.OR ENG
ADDRESS SPECIAL CIRCUIT 5.DO PERMIT VALIDATION
zIP EMP.METER OR POLE INS. .00
gPPLILANT'S MOTORS
ADDRESS S E FEE SCH. \ rr'VVV
¢ z SERVICE CHANGE
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02 LICENSED CONTRACTORS DECLARATION
R i w m
1 hereby iffm, that I am licensed under provisions of Chapter 9 .y 0
< (cumencuig with Section 70001 of Division 3 of the Business and e1 tl ISSUANCE DATE
z Oy i Processions Code,a¢{1 my license is in full force and eff c✓ BLDG. ELECT. PLG. MECH.
T - License Class t.-1t, Lia Number ❑ O ❑
wt: D°te U" Contractor
Q y F Y r
¢ w OWNER-BUILDER DECLARATION
A. 03 0 I hereby affirm that 1 am exempt from the Contractor's License MISC.— REFER TO OR < i'bIPGpMA 0
LL o j Low for the following reason.(Sec.7031.5.Business and Protbssions PERMIT ISSUANCE `/ALU I
m y Code.Any city or county which requires a permit to construct,al ter, S,OO q
¢ ¢ ¢O Improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO.
n w m¢ requires the applicant for such permit to file a signed statement that ELEC.
he 's licensed pursuant to the provisions of the Contractor's License TOTAL
� zQ LwIChaPer a(commenciagwilh Section 7000)ofDivision 3o fine +Tn%c' 'e'
Bus e s and Professions Code)Or that he is exempt therefrom and OTYe O PLUMBiNO{�@RMIT e.1 OL.yT C
I o the basis for the alleged exemption.Any viola Con of Section 7031 5 •, } i'yP su3 f sale�i3''r4:a'/"+ I
by any applicant for a permit subjects the applicant to a civil penalty STORIES TYPE CONSTR.
of not more than five hundred dollars(5500).): ALTER-DRAIN&VENT-WATER (EA.) 4.00
❑ I,as owner of the property,or my employees with wages as
their sole compensation,will do the work,and the structure is not BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP
intended or offered for sale (Sec. 7044, Business and Professions RES.UNITS
Code:The Contractor's License Law does not apply to an owner of DRAWS-FLOOR,ROOF,AREA,GOND. 4.00
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP
• himself or through his own employees,Provided that such improve- 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
ments are not intended Or offered for sale.If,however,the building GAS-EA.SV$TEM-1 IN .4 OUTLETS 4.00
Or improvement is sold within one year of completion, [he owner-
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00
prove for purpose of sale.). BUILDING USE
❑ 1,as Owner of the property, - INDUSTRIAL WASTE INTER. 20.00 RES IIN CON PB OO,
p perty,am exclusively contracting with
licensed contractors to construct the project IS, 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B.
and Professions Code:The Contractors License Law does not apply 5.00 ASSESSORS PARCEL NO.
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.)
contracts for such projects with a c.nt,a,t.NS)licensed pursuant to 1'�
the Contractor,License Law, SEWER-SANITAR V-STORM EA.200ft/8.00
❑ l am cxemPI ltodtr Sec. ,B.&P.C.for this TRACTNO. PARCEL NO.
reason WATER HEATER W/VENT q,DD
Owner Date
WATER SYSTEM q
WORKERS'COMPENSATION DECLARATION ACC.DATE ACC.FILE NO.
WATER TREATING EQUIP.
I hereby alfir.e of that I have a certificate of consent to self-insure, r
or a certificate of Workers'Compensa[i Insurance,or certified 20NIN0
{ cupy lherenry Sec.3800,Co pab.C.).�•7 P ENG.SITE NO.
Policy Nn. Company
gl/� _ x1__
O- ' ❑ Ce ;tied mpY is hereby furnished. 1 0
z 2 ertifed copy is filed with the city inspection division. FIRE SPRINK ENERGY T 24
F,—/O PPbcant i(w i Y❑ N Y C] NE)
—f e---.�I—IP'ga1�,/V MISC- REFER TO ORD.
CERTIFICATE OF E.XE.MPHON FROM WORKERS' PERMIT ISSUANCE 6.00
W > COMPENSATION INSURANCE I.G.PCONTH. FLOOD ZONE A.L.U.L.
CLO -- LIC.NO. DLG
(This secron need not he completed if the permit is for one TOTAL U Y El N Y NE]
L) 0 ad:certify
that In)the less)
I certify that m the tEmployperformance of the work for which this per,
lb-
mil is issued,I shall not employ any petmn in any manner so is to
Q Q. become subject to the Workers'Compenv[ion laws of California. I
W Date Applicant 4.f10 BUILDING fti
} m NO TICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADO TO MECH.
F- Z emptioo,you should become subject to the Workers Compensation APPLIANCE Provisions of the Labor Code, you must forthwith comply with 4.00 PLAN CHECK
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10Mr—F.M) 3.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER IOpODC,F.M) 5.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT)
the Performance o1'the work for which this permit is issued(Sec. 2.00
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
Lender's Name
Lender's Address HEATINGUNIT(OA/ER100,000B.T.U.)7.50 ELECTRIC
• Icertify that lhave read this application and statethatat the above VENTILATIONFAN(SINGLE) 3.00
information d curate[.1 agree to comply with all city and county
ordinances and state laws relating to building cont r It inn. and BOILER-COIaP(3 H.P.Or 100,000 B. 1.00 4.00 PLUMBING
hereby aulhoriee representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP* 1100.0008TU)SEEFEESCH. MECHANICAL
(We) agree to save, indemnify and keep hornless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which
may in an w acerae against said Ci onsequence of the PERMIT ISSUANCE 3,00 CONST.TAX
ng p 1 /y%1
4 �; `/ d• MECH.CONT. LIC.NO. TOTAL
\ / /
Signatu a of App........ onlraQor D le
OFFICE COPY