5611 (2) APPLICANT TO FILL IN INFORMATION WITHIN-RED LINES - USE.BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATION PERMIT NUMBER
a.I1.DING APPLICATION & PERMIT
AODREss _/.� ^ • ^���%_ , 5 611
(7�i/'� v` `J BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
OWNERS 2S`J�( M '{ {y$} 0413, " PLAN LHECK VALIDATION
NAME J JJ '4 '•kW - A R3 u
OT CTR Be PE AMITr
s,s. . m et'"-� ya a x a ���.w J �"
NONTRacTORs
NAME UTLETS-SWITCHES-RECEP 5.00/1.00
LIC.NO. LIGHTING FIXTURES 5.00/1.00 -
CONTRACTOR'sAPPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE - PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS - 6.00 PLAN CHECK FEE P.C.NO.
OR
' ENGINEER.
' tic.NO. SIGNS TRANS. 3.00
moo Ess ENG, SPECIALCIRCUIT -5.00 PERMIT VALIDATION
_ ZIP rFEMP.METER OR POLE INS. 15.00
APPLICANT'S MOTORSADDRESS SEE FEE SCH. Z
SERVICE CHANGE 10A0 �7/�/c�
La
o o LICENSED CONTRACTORS DECLARATION G
¢u 1 hereby aflhm'that I am licensed under provisions of Chapter 9 J CK —Z — ISSUANCE DATE.
in (nn nm encing With Section 7000)of Division 3 of the Business and
�i. a a BLDG. ELECT. PLG. MECH.
V i Professions Cndc,and my license is in full tome and effect. -- 0 ❑ O
z D m— License Class Lic.Number _
-o — Dote Contracmr
yrw
a [BUILDING PERMIT'
as OWNER-BUILDER DECLARATION k j-t--
Eos " MISC.— REFER TO ORD wO&p INFORMATIQN
E:
g LL N I hereby affirm that 1 um exempt from the Contractor's License
.. 0 J, Law fertile followingrcason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE - 6.00 VALUATION $/FT.
Code:Any city orcounty which requiresa permit to construct,alter,
as ¢ 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ` ELEC. -
O¢ requires the applicant for such permit to file a signed statement that ` TOTAL
a w LL lie Is licensed pursuant t0 the provisions or the Contractors License 1 PERMIT TO
Fzi
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe - '�- ,77{},$(f�
4 o Business and Professions Code)or that he Is exempt therefrom and GTYr:C W > T':PLUMBING'PERMIyTmk,p+F TM,i T FEES -`"( t�flor
¢ ro the bas is for the alleged exemption.Any violation efSectirn 70315 m� s`nT' - w ° ( 3a`.x -A" ti STORIES .TYPE CON TR.
aim by any applicant for a permit subjects the applicant to a civil penally - ALTER -DRAIN Of
ofnotmore than five hundred dollars($500t) �upQ(tlllO .
❑ 1,as owner Of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
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 docs such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for Sale If,however,the building GAS-EA.SVSTEM-111NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 eulLDlrvG USE
builder will have the burden of proving that he did not build or im- -
RES IND CON PS Other
prove 1,as ownerose
of It,
INDUSTRIAL WASTE INTER., 20.00 .
❑ L as nwner of the property,he exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business - LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Con tends o License Law does not apply
co an contracts
for
ouch prorty who builds actomi licensedthereon.and
Pursuant
who LAWN SPRINKLERS-OVER 5(EA.) 1.00 ,
contracts for such projects with n contraclots)licensed Pursuant ro
• the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exumpl lender Sec. ,B.&P.C.(or this WATER HEATER W/VENT 4.00 _
naso
Own Dale WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER,TREATING EQUIP., 4.00
I hereby affirm that I have a cerlilicateofconsenl toself-insure, - ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thercof(Sec.3800,Lab.C.). - - - -
Policy No. • Company
0 ❑ Cmlifiedcopyishercbyfumished FIRESPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.e— . REFER TO ORD.
0 Applicant - Y❑ No y❑ N❑
~ N - PERMIT ISSUANCE 6.00
� — CERTIFICATE OP EXEMPTION FROM WORKERS' FLOOD ZONE A.L.u.C.
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL 0 Irhis section need not be completed if the pernnt Is Rrr-one TOTAL Y❑ N❑ Y❑ N -
Z hundred dollars($100)ar less) N 'e'
U O 1 certify that In the performance of the work for which this per '"N4'N r Aa•k" °X' ` 'r "" lex j m„;s,: C FE SUMMARY
QTY s- MECHANICAL PERMIT `kUd%N `FEE
LL H Ncs
mit is issued,1 shall not employ any person in any manner so as to a t rg .W `�a a:,.M } -.tit., Y}'�. .•,ix�.b',� •s* .++ ��
O W become subject to the Workers'Compensation Laws of California. BUILDING G s�
0- Date Applicant - ALTER OR.ADD.TO MECH. 4,00 O
W NOTICE, TO APPLICANT: If,after making this Certificate of Ex-
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK -
provisions of the Labor Code, you must forthwith comply with .FEE
CJ such provisions or this pennit shall be deemed revoked. AIR HANDLING UNIT(TO 10)Of1DC-F.M.) ,_.3;00
CONSTRUCTION LENDING AGENCY' - AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance Of the work for which this permit is issued(Sec. - MICROFILM
_ 3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER) B.T.U.)7.50
Lender's Address ELECTRIC
I certify that 1 have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
( ordinances and State laws relating to building construction, and BOILER-CONIP(3 H.P.OF 100,000 B.T.U.) 4.00 —
hereby authorize representatives of this city to enter upon the BOILER-COMP(0Aar 100,000 BTU)SEE FEE$CH. MECHANICAL
above-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
may in any way accrue all Said City in consequence of the
gr ' g of this per "L MECH.CONT. LIC.NO.' MECH.
TOTAL
Signature Applicant(Con me o a
OFFICECOPY