6159 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
BUILDING PROJECT lDENTIFICATION _ /APPLICATION S! PERMIT
�( LDING
aoED IOPEssIf 67 VrA r..re ! BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 6 159
OWNER'b - r'\ h; tR• °. a PLAN CHECK VALIDATION
NA E
caorr�
PHorvrZ�Z"0,771 OTxVr. ELECTRICT'PERMIT1 .h#1' nFEE^1j..
Par s UTLETS-SWITCHES-RECEP 5.00/1.00
N4MF.
LIC.No. ILIGHTING FIXTURES 5.00/1.00
CONTRACTORS - APPLIANCES-RESIDENTIAL 4,00
ADDRESS
PHONE PANELS' 5.00 DATE OF APPLICATION
ARCHITECT SIGNS S.00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
_SS
zm TEMP.METER OR POLE INS. 15.00 ^
�
aooPEsS
APPLICANTS MOTORS SEE FEE SCH. (�Jv/7/4-
SERVICE CHANGE 10.00
o 0 LICENSIiU CONTRACTORS DECLARATION _
i I heruhy affirm that 1 thin licensed antler provisions of Chapter 9 _ ISSUANCE DATE
(commencing with Section 7000)of Division 3 of file Bminess and
Ci a N BLDG. ELECT. PLG. MECH.
D z 'Profession Code,and my license is in full force and effect
0 Z W License Class Lia Number ❑ 0 ❑ ❑
m H Uate - Contractor
P: u BUILDING7P,ERMIT yyy
¢ a OWNER-BUILDER DECLARATION
E:
3 LL r 1 hereby affirm 11, am exempt Innn file Contractor's License MISC.- REFER TO ORD '1'JNFORMATION„
Fa v, Law for tll a following reason.(Sec.7031.5,Business and Professio ns pERMIT ISSUANCE 6.00 VALUATION. WFT.
Code:Any city or county which requires a permit to construct,alter, �' '
¢ ¢ a0 improve, or repair any Structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
an D to requires the applicant for such permit to file a signed statement BsatTOTAL
A w m u-he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
FiQ Law(Chapter 9(commencing with Section 7000)of Division 3 oflhe
3 i D Business and Professions Code)or that Ile is exempt therefrom and OTY. PLUMBING PERMIT
(C ca the basis for the alleged exemption.Any violation of Section 7031.5 ` " ' ' ''_` STORIES TYPE CONSTR.
W 3 .2 by any applicant for A permit subjects file applicant to a civil penally ALTER-DRAIN&VENT-WATER (EA.) q.00 �(�@
of not more than five hundred dollars($500).): -100
❑ I,as than
of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
-their Sole compensation,will do the work,and the strucWre is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Low does not apply to an..net of
properly who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 50.FT,FLOOR AREA TOTAL ACREAGE
himselfor through his own employees,provided that such improve-
mentsarenolintendedoroffered for sale.11,however,the building GAS-EA.SYSTEM-l1NC.4OUTLETS 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-
pnwefor purposeol'sale.). ,: INDUSTRIAL WASTE INTER. 200p RES IND CON PB Omer
❑ I,as owner of the property,am exclusively contracting with ❑ 0 El C1 ❑
licensed contractors to construct the project(See.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:'I'lie Contractor's License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a conlractons)licensed pursuant 11)
SEWER-SANITARY-STORM Conlr'ctor's License Law. STORM EA,200ft/8.00 TRACT NO. PARCEL NO.
❑ la exempt under sec. ,li.&P.C.Rn this WATER HEATER W/VENT 4.00
reumn '
O"'ref 1)a10 WATER SYSTEM 4.00 ACC.DATE ACC.FILE N0.
'ORKIiRS'COMPF:NSATION DECLARATION. WATER TREATING EQUIP. 4.00
I crcby affirm Ihm I have a ce Compensation
of consent to sdf-insied
or a certificate of Workers'Compenudion Insurance,ar a certified ZONING ENG.SITE NO. '
ulpy thereof(Sec.3500,Lah.CJ. '
Policy N..-C(....puny
O ❑ Certified copy is hereby furnishedFIRE SPRINK ENERGY T-04
Z z ❑ Certified copy is fled with the city inspection division.
O Applicant MISC.- REFER TO OR Y ❑ N❑ Y ❑ NE]
I y CFRTIFICATEOF IiXEMp'I'I ON FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L-UL.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This action recd not be completed if the permit,is for one - TOTAL Y❑ At Y❑. N❑
Z hundred dollars(S 100)nr less.)
U O 1 certify that in the performance of Dm work for which this per- pTV:�: . MECHANICAL PERMIT FEE` 'FEEfSUMMr`AFRYAy? h
LL H mit is issued I shall not employ any person in any manner so as to -
O w become subject to the Workers'Compensation Laws of California.
Dam Applicant
CL ALTER OR ADD TO MECH. 4.00 BUILDING
>_ W NOT ICE'T0 APPLICANT'. If,after making this Certificate of Ex. .
Fz emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Ichor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=13.F.M.) 5.00 SEISMIC FEE tl
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(Sea 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.)7.50
Lender's Address ELECTRIC
IcerOly that l havercad this application and state that the above VENTILATION FAN ISINGLE) 3,00
// information is correct. I agree to comply with all city and county PLUMBING
1.F ordinances and state laws relating to building construction, and BOILER•COMP(3 H.P.Dr 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
abovo-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
consequence of the
ma in any way accrue avmsl said Cify in
gr' Ing of❑lis penya� ] MECH.CONT. LIC.NO. MECH,
X J9�/1/h /✓ //1 Lf1 �tl �'cF� TOTAL TOTAL'
Signutnre of Applicant/ContraC or Uate
0FFICE COPY ,