1206 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI. POINT PEN ONLY 41
1
• BUILDING PROJECT IDENTI FICATION PERMITN e
aDILDING APPLICATION & PERMIT O �`'"
ADDREss ,> v �!
ao6 S V C n BUILDING- ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S Jv ht_ `^-y'V,+;j kY �y, 4 h F.' > PLAN CHECK VALIDATION
NAME F ] A /r OTY e$ I ELECTRIC PERMITr t I FEE.; '
PHONE�.S J 4S.) t r T v r'a
CONTRACTORS OUTLETS
SWITCHES-RECEP 5.00/1.00
NRME
�l.P C LIC.No. ". /L LIGHTING FIXTURES 5.00/1,00
DONTRAc7oR's - PPLIANCES-RESIDENTIAL 4.00
ADDRESS C S L
C /e q•, PHONE - '9 -? PANELS 5,00 DATE OF APPLICATION
OR
SIGNS
6,00 PLAN CHECK FEE P.C.NO.
DR
ENGINEER -�GG
uc,no. SIGNS TRANS.
AENO. 6.00 PERMIT VALIDATION
' ADDRESSDDRESS SPECIAL CIRCUIT
ZIP EMP.METER OR POLE INS. 15.00
ARMOTORS SEE FEE SCH. s^/,/{,'.Ld•'
ADDRESS
Ess
'L F3 t $,act Loa I SERVICE CHANGE 10.00 /
woo LICENSED CONTRACTORS DECLARATION
Fu v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
x<vwAi (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT, PLG. MECH.
H w 2 Professions Code ym my license is in full far e1 or ❑ ❑ ❑
o us- License Class Lic.Number
u.w Date Contractor I,my ,
¢W< OWNER-BUILDER DECLARATION }=,BUIL IRMATIO IT \',4
Y REFER TO ORD INFORMATION�:7�{'..T
U
LL H I hereby affirm that 1 am exempt from the Contractor's License MISC.- VALUATION S/FT.
,Loa Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
,Awe Code:Any city or county which mquimsa permit loconstruct.alter,
c< improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC.
-o¢ requires the applicant for such permit to file a signed statement that P 2Q TOTAL 7 PERMIT TD
x m" he is licensed pursuant to the provisions of the Contractor's License
r i i Law(Chapter 9(commencing with Section 7000)of Division 3 of the "i'.' g���^�yq,`i,';aY:1•.::d='"'Crf.4ii},-'t•' �' L=; y ELL��-7 U�L
Business and Professions Code)or that he is exempt therefrom and DTV:i'sT?',v% i;•PLUMBING'PERMIT.vt.t !c T' -,',FEES,tr
¢I- the basis for the alleged exemption.Any violation of Section 7071.5 ;7:1 c;-7+'+ �'Vt.5>;4f' -c.�^.!-'!"=t';�:k;lk� ? STORIES TYPE CONSTR.
a. by any applicant forapermit subjects the appplicant to a civil penalty ALTER-DRAIN&VENT•WATER (EA.) 4.00
of not more than five hundred dollars(SS00).):
❑ 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 don not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00TQ FT.FLDOR AREA TOTAL ACREAGE
mems m through his own employees,provided that such improve-
ments
himself
f o not through his or employeeffered for,provided
that such
he building GAS•EA.SYSTEM•1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner. GAS-EASYSTEM-OVER 4 IEA.) 100 BUILDING USE
builder will have the burden of proving that he did not build or im- . .
RES IND CON PB Othar
prove for purpose of sale.). INCWTPLAL WASTE INTER. 20.00
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project ISec.7044,Business LAWN SYR I NC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to ao owner of property who builds or improves thereon,and who L R NKLERS• ER 5 IEA.) 1.00
contracts for such projects with a contractort s)licensed pursuant to
the Contractor's License Law. SEW •S IiY - TORM EA.200ft/6.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-.B.&P.C.for this WAT HEATERW ENT 4.00
reason
Date Owner WAT M 4.00 ACC,DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 4.00
I hereby affirm that I have a certificate ofconsent Io self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or It certified
copy thereof(Sec.3800,Lab.C.). RAMAb(.
PolicyJJ��O.-Company 'L('
O �Cerlifie opy is hereby furnished. SFIRE SPRINK ENERGY T24
Z Z ❑ Certs copy i fit with Ne sty inspection division.
O Applicant MISC.- y❑ N❑ y ❑REFER TO ORD. N
Y ❑
F•' rnPERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
ku COMPCERTIFICATE E EXEMPTION FROM WORKERS'
W � COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d O (This section need not be completed if the permit is for one TOTAL V❑ N❑ V ❑ N(]
Z hundred dollars IS 100)or less.) *i' . , =iA: . . `C r - - "r
U O I certify that in the performance of the work for which this per QTV x MECHANICAL PERMIT, " FEE'. i�• FEE SUMMARY,.-
ly F mil is issued,1 shall not employ any person in any manner
OW become subject to the Workers'Compensation Laws of California.
a Dale Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex.
� ? eruption,you the L become Code, you must Wrthwith comply with
APPLIANCE 4.00 PLAN CHECK
provisions i. the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10p00GF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.FM.) 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,Ch.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lenders Name HEATING UN IT(OVER 100,000 B.T.U.17.50 ELECTRIC `'
Lender's Address
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
information is correct.I agree to comply with all city and county BOILER-COMP13 H.P.Gr 100,000 B.T.U.) 4.00 PLUMBING
ordinances and stale laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP IOver 100,000 BTU)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 CONST.TAX
may in ny way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
gran f w PCrmll. MECH.CONT. LIC.NO. MECH.
tam /e,// & TOTAL TOTAL':
Signature- of�¢am/Control,or DU/c r I' "1'✓ Y?'
OFFICE COPY