13378 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT /� /�
GDDRE55 13378 J J O
1 111- SG�/s/I G. T3Ly O BUILDING-ELECTRICAL-PLUMBING-MECHANICAL I J J U
f .' 4Wry EH'a PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
» 11tE L4 i� OAJ"1 PRONE
i
cONTRACTOR's UTLETS-SWITCHES-RECEP 10.00/1.00 A
4)a BnOW4 COM LIC.14.,& �.Z�oy LIGHTING FIXTURES 10.00/1.00
CONTRACTOR Ss)RZ) `nAAlA/1A Ve APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PANELS 10.00
AR Ea.lrrsxa0 �4(= PHON / L DATE OF APPLICATION
ARC TECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER FE?
.1CA �AK>/aI1�C.No, 31878 SIGNS TRANS. 3.00
AR CH.OR ENG, PERMIT VALIDATION
ADDRESS 3s83 =NPa-1S"Wi 1 Qj VD m SPECIAL CIRCUIT 5.60 ,
A Aft0 GoIH�F zIP7 EMP.METER OR POLE INS. 20.00
APPLI SS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 II ?a 2: 1.../�e7L/r�
woo LICENSED CONTRACTORS DECLARATION h♦/Opp (d
Fu W I hereby affirm that I am licensed under provisions of Chapter 9 CIt O1' CB eV$�UANCE DATE
a a' (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H D z Professions Cod nA my license is in full fore e( ct. 2 ❑ ❑ ❑
o i'i w License Class Lic.Number
ate 7 Contractor .
0
Lt J i
J• BUILDING PERMIT
ow )OWNIiR-BUILDER DECLARATION INFORMATION
w ;is. I- I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
Fu Ow VALUATION $/FT.
a Law for the following mason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
as J Code:Any city orcourty which requires a permit to construct,alter,
w..4.�1
improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
C u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w$ he is licensed pursuant to the provisions of the Contractor's License 1
i
iiLow(Chapter 9(commencingwithSection 7000)ofDivision3oftheC7��Yx/r
a Business and Professions Code)or that he is exempt therefrom and DTV, PLUMBING PERMIT FEE
H$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d ;
by any applicant for a permit subjects the applicant me civil penalty ALTER-DRAIN IEA.) 5.00
gLTER- r
ofnot more than five hundred dollars 05000,): 410 W �..�-
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the straclure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
/o Code',The Contractor's License Law does not apply to an owner of
4L,I, property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
;.
v;I himself or through his own employees,provided that such improve- GAS-EA.SVSTEM-11NC.40UTLETS 6.00
/
+MT ments are not intended or offered for sale.If,however,the building
n or Improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
RES IND CON PB Otherprove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
O 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.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's 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 for such projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPF-NSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm taut 1 have a certificate of consent to self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Comp ns ti�IIsurance,or o certified
copy thereof(Sec.3800,Lah.C.)�
Policy No.-Company6C, L0017AOI GPA
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGYT 24
Z 2 ❑ Certifmd copy is 01e with the ppity inspection division.
Applicant •'i"1-aip7Ao•V-rJ - MISC.- REFER TO ORD. v ❑ N❑ v ❑ N❑
~ 0PERMIT ISSUANCE 10.00
LU - CERTIFICATE EXEMPTION FROM WORKERS' FLOOD ZONE A.L.U,C.
W � COMPENSATION INSURANCE, PLG.CONTR. LIC.NO. PLG
CL a Z (This section need not be completed if the permit is for one TOTAL Y❑ _N❑ Y E] N[3
hundred dollars($100)orless.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL'PERMIT FEE t FEE SUMMARY
W F 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.
y Dale Applicant ALTER OR ADD TO MECH. 5.00 BUILDING 5C./C,C4
�- N NOTICE TO APPLICANT: If,alter making this Certificate of Ex-
? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 6.00 SEISMIC FEE Zd�
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). I HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
t"IIIIIII certify that Lhave read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and countyPLUMBING
ordioances'and state laws relating to building construction, and BOILER-COMP Q H.P.Or 100,000 B.T.U.) 6.00
p hereby authorize representatives of this'city to enter upon the
above-mentioned property far inspection purposes. BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD:
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue againsVsaiVCity in consequence of the PERMIT ISSUANCE 10.00
granting of this permit MECH.CONT. LIC.NO. MECH.
TOTAL te
TOTAL S °
Signator of Applicant/Co actor Dale
OFFICECOPY - -