6013 (2) I APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT'PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING - + '. • APPLICATION & PERMIT
AD BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 6011'.
1 1
O.NER
s is w Y� •- PLAN CHECK VALIDATION
NAM
r 6fv t '•RELECTRIC•PERMIT Y,+ ' t4FEE�,'
ONE Y '
NANrRAcroRs UTLETS-SWITCHES:RECEP 5.00/1.00
NAME
LIGHTING FIXTURES 5.00/1.00
r,ONTRAcrons ', >, pPLIANCE6:RESIDENTIAL :4.00
7C. -�sl qOx Z�),� pIl l� _ 6 PANELS - 5.00 DATE OF APPLICATION
ARCHITECT ' SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
uc.rvo. ISIGNS TRANS. 3.00
ARCH.OR ENG: SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
AOOREss
ZIP EMP.METER OR POLE INS. 15.00
APPLICANT'S
ADDRESS MOTORS SEE FEE SEH. y/
- + SERVICE CHANGE 10.00 �9! �O
T O LICENSED CONTRACTORS DECLARATIONto G
Q U v I hereby affirm that 1 ton licensed under provisions of Chapter 9 ISSUANCE DATE
EEi a N f.mmne.eing with Section 7000)of Division 3 of the Business and Z BLOO. ELECT. PLG. MECH.
H m z Professions Co��jjuuss mLLyy+ ¢eau rs in full fore
i o,n' Liceny Class C� Con Number tr tracto ❑ ❑ ❑ ❑
¢ x isBUILsDINGPERMIT
¢ ¢ w a OWNIi R-BUILDER Df:C1.ARATION :
ods' ��- MISE.- REFER.TO'ORD
INFORMATION
w;LL H I hereby affirm(fiat I am exempt from the Contractor's L cenu
I-LL O; Iaw for the following reason.(See.703 1.5,Businessand Professions PERMIT ISSUANCE VALUATION S/FT.
w'4 Code:Anycity orcounly whichrequiresapermittoconstruct,allcr, 6.00 ''11
¢ ¢Q 2O improve,demolish,or repair any structure.prior Io its issuance,also ELEC.CONTE. LIC.NO. ELEC. V Otl
D.Se requires the applicant for such permit to file a signed ShAcmenl that TOTAL PERMIT TO
a w m he R licensed pursuant to the provisions of the CoNrnctor's License ,� r
H z i I.aw(Chapler9(colnmencingwl(ll SCctlun7o00)u(Division3ofth w.'Q,li. x+)ns v t t Si'.13 �, /�0� 4C�
4 o IiuRness and Professmns Code)or that he is except therefrom and OTY� qM Ye,� 4PLUMBING'PE WIT s.`i_ JF�E FI
the basis for the alleged exemption.Any violation of Section 7031.5 t< t_ ' ,ry�'` STORIES• TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.14.00 CItGC�IH(YiJ.Kfi
of not more than five hundred dollars(5500)J: ++�•'llll"'""'''^^'"""''^^^�
❑ I,as
owner of the property,or my employecS with wages as BACK FLOW PROTECT.DEV ICE 2,00 OCC.GRO RES.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,GOND: 4.00 �, r44
Code:"The Contractor's License Law docs not apply to an owner of
property who builds or improves themon,and who does such work F IXTUR ES-PER TRAP - 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees.provided that such improve.
meats arc not intended ar offered for sale.l f,however,the building GAS-EA.SYSTEM-I1NC.40UTLETS 4.00
or improvemenl is sold within one year of comple(ion,+he owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
to Ider will have the Burden of proving that he did not build or im-
prove list purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 RES IND cool PB otna.
D I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.O. 5.00 ASSESSORSPARCEL NO.
anJ Professions Code:The Contractor's License Law docs not apply
to an owner of property who builds or improves Ihcrcon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
- cnnlruuls for Streit p ejects wi Dl n confraor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO, PARCEL NO.
O 1 am exempt under Sec. ,If.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner. Dale WATER SYSTEM 4.00 Acc.DATE ACC.FILE NO.
WORK Ii RS'COM PENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate ofeDnsont to self-insure, ZONING ENG.SITE NO.
.1.1 certificate of Workers'Compensatio0•Insyrarme,/af a cerlil'ied '
copy thereof(Sec.3 Lab.C.lfjt .11�r.RR.-�fLL((,,�_,, -
Policy No. Co pany(�'
Q ❑ Cartlfed,eop is'h re ishe'. �0 FIRESPRINK ENERGY T-24
Z Z M_C fled w he city in: coon isi n,
4 MISC.- -� REFER TO ORD.
0' ppicanl - _ YE]. N❑ V ❑ N❑
= rn CERTIFICA'I'li OF EXEMPTION F-ROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.c.
CONI PENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
'd 0 (Phis section need not he completed If lire permit is for one TOTAL Y❑ 1 Y❑ N❑
Z bundmddollars 1$100)or less) - < - u=]P{m
k. M
U O I certify that n tlIc performance of the work for which Onsper-er QTV++.x MECHANICAL PERMIT*'r� FEE `+-FEE SUMMARYk
IM
LL F ton Is Issued,I shall not employ any person In any Inanner so as a ^.1, .
U become subject to the Workers'Compensation Laws of California. Sea
� a Date Applicant- ALTER OR ADD TO MECH. 4.00 BUILDING -_
>: ea NOTICE'10 APPLICANT: If,after raking this Certificate of Ex-
H Z emplion,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 pruvielons or thin permit shall be deanmd revoked. AIR HANDLING UNIT(TO 1000D11F.M.) 3.00
CONS'I'RUC CN LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the perk rmance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,CIv.C.).
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address - - - ELECTRIC
I certify that I have read this application andstate that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
drdlnences end slam laws relating to building construction, and BOILER-COMP 13 H.P.or 100,000 B.T.U.) 4.00
hereby authorim representatives of this city to enter.upon the BOILER-COMP IG Ver 100,000 BTU)SEE'FEESCH. MECHANICAL
above-mentioned property for inspection purposes,
(We) agree to .'vq indemnify and keep hion less'ttie City oI MISE.- REFER TO ORD.
Cupertino ago st 1 a ' s,judgments, costs and expenses which CONST.TAX
ma in an y core abut said Fity consequence of the PERMIT ISSUANCE 3.00
un mg ¢ err it, MECH.CONT. LIC.NO. MECH.
TOTAL
$ignah P TOTAk )
re
p
OFFICE COPY