7123 (2) -APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -, USE BALL POIN- •PEN'44)NLY
. BUI LDI NG PROJECT I DENTI FICATION PERMIT NUMBER,
ED LOING APPLICATION & PERMIT
A°°nEas r
'1Zl'STi-"UDHQLLgUBUILDING-ELECTRICAL-PLUMBING-MECHANICAL 7123
I OWNER'S '. 1y a -kK.y ggt P T. PLAN CHECK VALIDATION
ry NAME OTaVF. wl "4A
,1-7?5.•"Ti-,¢rj va R,iy "~f9 F.W :
y �./� ELECTRIC)PERMIT 4 EEx
.W . x�Q(: � ' PHONEz '-sV
` NAMERACTDrrs OUTLETS-SWITCHES-RECEP 5.00/1.00
�cx
LIC.NO. LIGHTING FIXTURES 5.00/1.00
CONTRACTOR's
•AOOHEss' APPLIANCES-RESIDENTIAL 4.00 -
PHONE PANELS 5.00 DATE OF APPLI CAT ION
OR
SIGNS 6.00 PLAN CHECK7F7 P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP ' TEMP.METER OR POLE INS. 15.00
Ais
AODRESS MOTORS FEE SEE EE SCH.
SERVICE CHANGE 10.00 U
w o o LICENSED CONTRACTORS DECLARATION
au I hereby affirm tool I'am licensed under provisions of Chapler 9 ISSUANCE DATE
z lu (commencing with Section 7000)of Division 3 of the Business and
Q n BLDG. ELECT. PL ECT.
F N z Professions Code,-and my license is in full force anJ effect.
oi w W License Class 'Lie.Number -
F w l_ ca Dale Contractor I
mER - BUILDING E MIT,
¢ a OWN -BUILDER DECLARATION w--�--
IQ
E:
;LL w thereby affirm that I am oxempt Irnm the Com rucbsr's License MISC.- REFER TO ORD `s'+rv..IN FORM T N
F LL m j Law for the following reason.(Sec.703 1.5,Businessand Professions PERMIT ISSUANCE 6.00 VALUATION $/FT.
Code:Any city or county which requires a permit to construct,alter,
Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O ¢ reRvires Bre applicant for such permit to file a signet]statement[hat TOTAL
a w m he is licensed pursuant to lire provisions of the Contractor's License PERMIT TO
is
Law(Chapter 9(commencingwlth Section 7000)of Division 3 ofthe -
zc Businessand Pro]'cssions Code)or that he isexempt therefrom and OTY,. PLUMBING PERMIT 'r�`�':' ycfFEE
¢F m the basis for the alleged exemption Any violation of Sr6(ion703I.5 `. r`.?7� STORIES CONSTR.
d3 � by any applicant for a permit subjects lire applicant to a civil penally' ALTEfl-DRAIN&VENT-WATER (EA.) 4.00
of nor more than five hundred dollars(1500).):
❑ I,as owner 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 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 docs 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
ry himself through his own employees,providereal such improve-
Routs arere not intended or offered for sale.If,however,the building GAS-EA.SVSTEM-11NC.40UTLETS 4.00
t r improvement is sold within one year of completion, LOU owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
b� buil r will have the burden of proving that he diJ act build ar im-
Zrt, for Purpose of sale.). IND CON PB Other
I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ 0 0
tic nsed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PAR CEL NO.
and Professions Code:The Contractor's License Law does not apply to an owner of property who builds or improves[hereon;and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 '
Con ets for such projects with a contracrods)licensed pursuant to
ntractor's License Law. SEWER-SANITARY-STORM EA.2001t/8.00 TRACT NO. PARCEL NO.
I Am exempt wider Sec. ,B.&P.C."'Ti. WATER HEATER W/VENT •4,00
as
X wncr_ Dated WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
O KERS 0 PENSAT'ION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm That I have a certificate of consent to self-insurc, - ZONING
or a certificate of Workers Compensation Insurance,or a Certified ENG.SITE NO.
copy thereof(Sec.3800,Ub.C.).
Policy Nvi Company _
0 ❑ Certified copy is hereby furnished, FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with rbc city inspection Division. MISC. REFER TO ORD. ❑
O Applicant V N V N
~ y
K CIiRTI PICKI'EOPIAX TIPPERMIT ISSUANCE 6,00 ROM FLOOD ZONE 0.LU.C.
W 7 COMPENSATIOiON INSURANCE PLO.CONTR. LIC.NO. PLG
ZJIL (This section need not be completed if tire permit is for one TOTAL Y N� V NEI
hundred dollars(S 100)or less.) - y,a-'.Ia
U O 1 certify that in the performance of the work for which this per QTY 5-`i -*' y.q 5, r °" '"c'` F iFEE SUMMARY
a w '-MECHANICAL;P.E RMIT IV -FEE .�'=c„e„eaSU
LL H mit Is Issued,I shall not employ any person in any manner so as to ,g'vf d , I",L u;
0 W become subject to the Workers'Compensation Laws of California.
y Date Applicant BUILDING
} N NOTICE TO APPLICAN'C If,after making this Certificate of 17x- ALTER OR ADD TO MECH. 4.00
I. ? emption;you should become subject to the Workers'Compensation APPLIANCE 4.00PLAN CHECK
provisions of lire Labor Code, you must fortbwirh comply with FEE _
U such provisions or[his permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000CF.NL) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IOX13C.EM.) 5.00 SEISMIC FEE
I hereby affirm lust there is A construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance o]'the work for which this permit is issued(Sec. MICROFILM
3097,CR,C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00 -
Lender's Name H EATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that l have read this application and slats that the above VENTILATION FAN (SINGLE) 3.00 /
Information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 - PLUMBING (O
ordinances and state laws relating to building construction, and
I hereby auth°riee representatives of this city to enter upon the BOI LER-COMP (Over 100,000 BTUI SEE FEE SCH. 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 ecrue against said City in consequ oce of the
in oftlis Ir MECH.CONT, LIC.NO. MECH. -
2( 85 TOT" TOTAL
Si at eof App' an Contractor' Date _
! OFFICECOPV t