5952 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
To'WING APPLICATION & PERMIT"
A OORESS
BUILDING—ELECTRICAL—PLUMBING—MECHANICAL 5952
ONAME a `F=8'n -� " '"" �glFy As - 'p PLAN CHECK VALIDATION
1 (f/ — - ` QTY': T K,aECECTRIC`PERMIT «* I, � FEE A
PHONE t 'S, ,.riq
CONTRACTORS
NAME `� OUTLETS-SWITCHES-RECEP 5.00/1.00
T LIC.NO. ala LIGHTING FIXTURES 5.00/1.00 _ -
GONTEACTOR9i�DgSlPPLIANCES-RESIDENTIAL 4.00
r� NVvyt 1 PHON�,(—/LJ0AO PANELS J 5.00 DATE OF APPLICATION
ARCHITECT SIGNS S.00 PLAN CHECK FEE P,C,NO.
DR
CNGINEER
' uc,No. SIGNS TRANS. 3.00
ARCH.ss ENc. SPECIAL CIRCUIT 5.00 PERMITVALIDATION
ZIP rrEMP.METER OR POLE INS. 15.00
CA
I
APPLS
APPI CA - MOTORS, -SEE FEE SCH.
SERVICE CHANGE 10.00
woo LICENSED CONf RACI'ORS DECLARATION
rt v w '1 hereby affirm that I am licensed under pnwisinns of Chapter 9, ISSUANCE DATE
yNcR unencing with Section 7000)of Division 3 of the Business and
<u -I� O BLDG. ELECT. PLG. MECH.
F m i P...(cssions C. E, my license on full h n effeSt T x ❑ ❑ ❑ ❑
Z o m.— License Class Lie.Numbe f—).l
r w Date Ss U Contractor
BUILDING PERMIT
¢ ¢o i o OWNER-BUILDER DECLARATION INFORMATION
wg LL N I hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD
s- LL 0 as Law for the following reason.(Sec.7031.5,11minessand Professions PERMIT ISSUANCE 6.00 VA ti
in vt Code:Any city or county which requiresu permit to construct,alter, i[�a�
¢ , ¢ O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO.' ELEC. T
Do¢ requires the applicant for such permit to filo a signed statement that TOTAL MI
a w mhe is licensed pursuant to the provisions of the Contractor's License
i
Law(Chapter 9(commencing with Section 7000)of Urvision 3 of the
iao Business and Professions Code)or that he is exempt therefrom and QTY.YfF�a� syg s,PLUMBWGPE'RMIITti`y'+` FEE LR.oO� �Jz
¢r$ the basis for the alleged exemption Any violation of Section 7031 5 "" •"A, k CONSTR.
a ; � by anyapplicant for.
vehundpermit subjeco(the$50pplicam toacivilpenalty ALTER-DRAIN of not mom than five hundred dollars(my cm): a�t
❑ Las owner of the will do t or my,and t e s with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC. OUP RES.UNITS
lith sole compensation,will(S the work,and the structure is not
intended or offered for sale sect. 7044, Business end Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00 �o /V !LS
Cole:Tye who
License Law does not apply loan owner of
property who builds or Improves employees,
pr and who docs such work FIXTURES-PER TRAP 4.00 SO.FL FLOOR AREA" TOTAL ACREAGE
himself m through his own eared for
provided that such improve
nienis ore not intended or offered far safe If,however,the building GAS-EA:SVSTEM-11NC.40UTLETS 4.00
or improvement is sold within one,year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.1 1.00 BUILDING USE
builder will have the burden of proving Thal he did not build or am. RES IND CON PB Omer
Prove for purpose of e.). h INDUSTR IAL WASTE INTER. 20.00 1:1 El El ❑ El
I,ass owner
th
of the properly,am exclusively contracting with
licensed contractors to construct the project ISce.7044,Busincas LAWN SPO IN KLERS=1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Cnde:The Cmiton u-a License Law Jars not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1,00
contracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License l.aw. SEWER-SANITARY-STORM EA.200ft/8.00 TRACTNO. PARCEL NO.
❑ I am exempt under Sea ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner - Data WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORK RRS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby of on that I have a Certificate of consent to selEinsum, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
Copy thereof(Sec.3800,Lu1j.-)
,Policy No. Company�l�G TY9_7_
❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T-24
Z_ Z ❑ Cert i opy s i •d with the city inspection division. MISC- - REFER TO ORD.
Applicant C V❑ N❑ V ❑ IN E]
F— �+ PERMIT ISSUANCE 6.00
c CERTI I4CA' I'IiXIiMI'T NFROM WORKERS' FLOOD ZONE A.L.U,C.
LU COMPENSAj'ION INSURANCE PLG.CONTE. LIC.NO. PLG.
Z z (This section need not he completed if the permit is for one TOTAL Y❑ N❑ Y❑ NEI
hundred doll...(S 100)or less,) -
U O 1 certify that in the performance of the work for which this per. ° .t r § _k x' 'n ','xkaFE E+SUMARV c
QTV•'A"�'. ,'-MECHANIQAL PERMIT . `•a+ sFEEA x, M
LL I— mit is issued,I shall not employ any person in any mannerso as t y w ,„ `' S,e -
Q w become subject to the Workers'Compensation Laws of California.
n Dam 'Applicant ALTER OR ADD TO MECH. 4.00
BUILDING s"D f�
} N NOTICE—TOAPPLICANT: IL after making this Certificate of F.x-
F-. ? cmption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
prisions of the Labor Code, you must forthwith comply with
U sucovh provisions or this permit shall be deemed revoked - AIR HANDLING UNIT(TO 10/100C.F.M.) 3.00 FEE
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10000 C.EM.) 5.00 SEISMIC FEE a�
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(Sec. MICROFILM
3097;GYC.I .. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)7.50
Lender's NaJress ELECTRIC
I certify that I have read this application 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 sLate laws relating to building construction, and BOILER-COMP
(3 H.P.Of 100,0008.T.U.) 4.00
hereby authorize representatives of this city to:enter upon the
above-mentioned property for inspection purposes. BOILER-COMP(Over 100.000 BTU)SEE FEE SCH. MECHANICAL
(We) agree In 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
May in any way accrue against said City in consequence of the
gr togofthispcRnitMECH.CONT. LIC.NO- MECH.
TOTAL YOTAL�;'
Signatumot Ap ant/ ontrac r Dale -
OFFICE COPY ,