5121 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION .. PERMIT NUMBER
aDILDING, APPLICATION & PERMIT I ��
AODRE
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 1
I
NAME
OWNED :l �, ` fes.Yrs ki .2 fid ).` PLAN CHECK VALIDATION
OTY.. ,, ✓-4' ELECTRIC<PERMIT �'"_y' '�'+'7i 7ti",F.EE iu
y n
' ) ��2oLdh &M ONE
CONTRACTORS OUTLETS-SWITCHES-RECEP 500/100
NAME
Q( LIC.NlC)y qLDL4 LIGHTING FIXTURES 5.00/1.00 '
CONTRACTORS
A GDRESS L415) APPLIANCES-RESIDENTIAL 4.00
i- PHOry PANELS 5.00 DATE OF APPLICATION"
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER - '
LIC,No. SIGNS TRANS. 3.00 -
ADD Eis ENG" SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 15.00
APPUQANrs MOTORS .SEE FEE SCH,
aooREss
IQA 4 . SERVICE CHANGE 10.00 PAID
02 LICENSEE)CONTRACTORS UF;CLARATION �d --
a u u '1 hereby affirm that I am licensed under provisions of Chapler 9 I ISSMEDATE
wZ , (Commencing with Section 7000)of Division 3 of the Business and
a BLDG. ELECT. PLG. MECH.
'a Professions Co�j �rII^�d m license is in full fore qgII���yy[[jjeel ❑ ❑
Z O.; License ClassSir_L1D�Lic.Numbefj-:2LlLs'LID4 s
9 Z r w' Date Cnnlractor a6' ti ID
a m it 4 q, "jBU1LtDING PERMIT
rc ¢ OWNI>&dUILDIiR DECLARATION •' '^.
a o d u '7 INFORMATIONBMW
E
; LL N I hereby affirm that I am exempt from the Contractor's License MISC.- _ REFER TO ORD
H u 0 a Law for re following reason.(Sec m
7031 5,Busessand Professums PERMIT ISSUANCE VALUATION SIFT.
a
Code:Any City orcounty,whicbrequiresapurmnloconstrocLatter, 6.00
Q a,> improve,demolish,or repair any structure.prior m its issuance,also ELEC.CONTR. LIC.NO. $LEG I W M�(�/Rn/J)
IS requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w w u he is licensed purseml to the provisions of the Contractor's License
i I.aw(Chapmr9(commencingwlthSecllon7000)ofDlvtsimn3oftb 4+W '±N" I _ d3fif #,x..ba )-, iPw'f
io Business and Professions Code)or that he Is exempt therefrom and OTV t +4y." `{PLUMBING PERMIT' ,'" 4 ;;,.,FEE '1
¢ t-m the haws for the alleged exemption Any violation of Section 7031.5
- ``�..':i' '$ STORIES TYPE CONSTR.
La3 - by any applicant for a permit subjects the applicant(uncivil penally ALTER-DRAIN -WATER IEA.) 4.00
of not more than five hundred d.1hus($5001.): '
❑ I,as owner of(be property,or my employees with wages re BACK FLOW PROTECT.DEVICE 2.00 �OCC.GROUP RES.UNITS -
theo.,to Compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions - DRAINS-FLOOR,ROOF,AREA,COND. 4.00 ,
Code:The Contractor's License Law does not apply to an owner of
` property who builds or improves(hemon,and who does such work FIXTURES-PER TRAP 4.00 SD.FT.FLOOR AREA TOTAL ACREAGE
himsellor through his own employ",provided that such improve-
mentsamnotintendedorofferedforsale.If,however,the budding GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is add within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1,00 BUILDING USE
builder will have the burden of proving that he did not build or im-
proveforpurposeofsale.). INDUSTRIAL WASTE INTER. 40.00 RES IND CON PR Other
❑ 1,as owner of the propemy,am exclusively contracting with ❑ '0 1-1 ❑ 1-1
licensed contractors to construe( the project(Sec.7044,Business LAWN SPRINKLERS-I INC 5 V.B. 5.00 - ASSESSORS PARCEL NO.
and Professions Code:The Contractors License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts fur such projects with a contmelods)licensed pursuanl to
- the Contractor's License Law. SEWER-SANITARY-STORM EA.'2001t/8.00 TRACT NO. PARCEL ND.
❑ Iain exempt under Sec.-.BAP.C.for lhis WATER HEATER W/VENT 4,00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK I:RS'COMPFNSATION DECLARATION WATER TREATING EQUIP.. 4.00
I hereby affirm that I have a certificate of Consent In self-insure, 20NING" ENG.SITE NO.
or a certificate of Workers
Compensation Insurance,or certified
COPylhcr�•of($Cy. R00,LahC `
Poliyf NA'�6h CompanY � ' :E(AA mn it
id Certified copy is herebyfurnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified Copy is Bled with the city inspection.division.
O Applicant MISC.- REFER TO ORD. YC] NE] Y [] NE
m y CERTIFICATE OF Iixim-TION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.0 C:
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG, O N v N�
d o (This section need of he completed if the permit Is for n TOTAL v
Z" 'hundred dollars(S 100)or less.) _ -
U O 1 certify that In theperformance of the work for which this Per
f'v" 'I gg`�. ° �+ ' v `"'v'i•' fP "" , FEE SUMMARY i
ti F
mil Is Issued,I shall not employ any person in any manner so as rn UTjYf @v }` +r,MECHANICALwPEflMITT
O Uy- become subject to the Workers'Compensution Laws of Cahforme
, "Vale Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
mIDaO�
} W NOTICE TO APPLICANT: If,after taking this Certificate of Lx- W
? 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 prnvisinns or this permit Shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.NL) 3.00
CONSTRUCTION LENDINGAGF.NCY AIR HANDLING UNIT(OVER 10=1 .F.M.) 5.00 SEISMIC FEE (r
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. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ.C.).
Lender's Name HEATING UNIT 100,000 B.T.U.17.50
Lender's Address - ELECTRIC
1 certify that I have read this applicalion and state that the shove VENTILATION FAN (SINGLE) 3.00
information is correct.I agree to comply with all city and county - PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP13 H.P.Or 100,000B.T.U.) 4.00
hereby authorise representatives of this city to enter upon DIC BOILER-COMP(Over 100,000 BTO(SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes,
(We) agree to save, indemnifyandkeep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may 'n any waycrue against said City in consequence of[he
Its i g fthi,PCI iL MECH.CONT. LIC.NO. MECH.
6 TOTAL TOTAL,,` 8-d
Sig lure of Applicant/Contractor Date
OFFICE COPY.` '