5949 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL P01NT PEN ONLY
'BUILOING PROJECT I DENTIFICATION ';r PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS 5949
330' ScFiV/G . LV BUILDING-ELECTRICAL-PLUMBING-MECHANICAL •
WNER'S PLAN CHECK VALIDATION
"AM�ETV. _ ELEC}TRIC PERMIT FEE
CONTRACTORS
NAME UTLETS-SWITCHES-RECEP 5.00/1.00
NAME
uC.No. LIGHTING FIXTURES - 5.00/1.00
r.ONTRACTOWS -
...REss -APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 v DATE OF APPLICATION
ARCHITECT - SIGNS 600 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
DDRSS
ZIP rrEMP.METER OR POLE INS. 15.00
APPLICANT SMOTORS SEE FEE SCH.
DRESS
ADDDRESS
SERVICE CHANGE 10.00
,02 I-ICIiNSISD CONI'kACfORS DECLARATION
Se U U '1 hereby affirm thin I ant licensed under provisions of Chapter9 ISSUANCE DATE
'y<w, (commencing with Section 7000)of Division 3 or lite Business and - BLDG. Ego PLG. MECH.
r w z Professirns Code,and my license is in full force and effect.
O m- License Class Lic.Number
'O Dae Contractor ❑ ❑
'+�B_U.ftDIIN.,G�'P�ERMIT
a ¢w u OWNER-BUILDER DECLARATION 'bCl p.N' FORMA\TION
So
;LL y -I hereby affirm That 1 am exempt from the Contractor's License MISC.- R ER TO ORD --
at 0 < Law for lire following reason.(Sec.7031.5,Businessand Professions
PERMIT ISSUANCE 6.00 VALUATION $/FT.
Code:Any city or county which requires a permit to cord ruct,alter,
8, toQ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTH. LIC.NO. ELEC.
u iL m u. requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
Hii Law(Chapter 9(commencing with Section 7000)offivision 3 ofthe -'l'E"q;,'
E z o Business and Professions Code)or that he is exempt therefrom and CITY. - PLUMBING.PERMIT
¢ H $ the basis for the alleged exemption.Any violation of SCClion 7031.5 - ' "'& R STORIES TY CONSTR.
ag by any applicant for a permit subjeclslheapplicanl toacivilpenalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(5500).):
❑ I,its owner of the properly,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 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 thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself Or through his own employees•provided that such improve.
Frontsorb not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,lite owner. GAS EASYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that h - .e did not build or im- -
provefor purp2cofSulo.). � INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB Omer
RES
as owner of the property,am exclusively contracting with ❑ ❑ [1 : ❑ ❑
licensed contractors to constrict lite project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner or property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
iioroF}Icts for such projects with a contractor(s)licensed pursuant to
Ol corador's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
��I m cxcm t I cr S ,B.BU'.C.far this WATER HEATER W/VENT 4.00
`/ 01
r Ow" - Dom WATER SYSTEM 4.00 ACC.GATE ACC.FILE NO.
WORKF:RS'COMPHNSA'I'ION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby alfinn that I have a certificate of consent to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.3800,I.A.C.).
Policy No. Company
Q' ❑ Certificdcopyislnerebylurnlshed' Y FIRESPRINK ENERGYT24
Z Z ❑ Certified copy is filed with the city .......cutin division.
p: O Applicant MISC.- - REFER TO ORD. y N❑ To N[]-y PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU Clik'I'I I'ICATECA EMPT ION FROM WORKERS'
-W � COMPEF.NSA'1'ION INSURANCE PLG.CONTR. LIC.NO. PLG.
EL O (This section need not be completed if the permit is for one . TOTAL Y❑ N Y ❑ No
Z hundred dollars($100)or less.)
U O I cerOf that in the performance of the work for which this er a,'y q.y `-.>r•Sic
LL F- mil Is issued, l shall not employ any person in any intoner SO os t r �TV " � 35'x ,MECHANICAL�PERMITiry.,2x tro FEE'p '`�, ,,%F�EE�SUMMA�RV
O W hccome subject to lire Worker'Compensation Laws Of Culiforma. `
y Dule Appli°°nl ALTER OR ADD TO MECH. 4.00 BUILDING
} to NOTICE TO APPLICANT': If,after making this Certificate of Ex
2 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 provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10100DCF.NL) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=1 F.M.) 5.00 SEISMIC FEE
I hereby alfinn 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,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.P.50
Lender's Names ELECTRIC
I certify that l have read this application and slate that lite above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county gOILEfl-COMP(3 H.P.Or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and slate laws relating to building construction, and
hereby aulorio ed property for inspection of
purposeses
representatives f this city enter upon the
herebymenlBOILER-COMP(over 100,000 BTU)SEE FEE SCH. MECHANICAL
mn .
' (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
I• may in any way accrue against said City in conssaim nce of the
gra ing of this pe iL C MECH.CONT. LIC..NO, MECH.
- TOTAL
"
\/ .((l[ x LLfl :TOTAL '..
Ignatareof Appllcant�Con(ractor a Data
OFFICE COPY •_�