7067 (2) - it-
PPLICANT TO FILL.IN INFO ATION WITHIN RED LINES - USE BJJL POINT PEN ONLY
BUILDING PROJECT IDENTIFICA PERMIT NUMBER
BUILDING APPLICATION & PERT 7067
aoonesas/7/ O g-rojM K:WQBUILDING_ _ _ _ _
oC f0 -,ELECTRICAL-PLUMBING-MECHANICAL
PLAN CHECK VALIDATION
.� NAMEDTV. ELECTRIC gERMIT FEE
2q_ 52-0'LTF4 -HuZO* '
e.
PHONE
CONTRACTOR'S sT it> UTLETS-SWITCHES=RECEP 5.00/1.00 Z,
NAMIi�G - ?-
RIJZ6i'fi4-- - LIC.N." / LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S
ADDEess Z•Z a p-rai'hh �r-A./ PPLIANCES-RESIDENTIAL' 4.00
p-��x�� .k�R��M P-ONE'ai /�7II PANELS .'5.00 DATE OF APPLICATION
-� ARCHITECT `"�'Ga/ v.�+'--' SIGNS
g.00 ' PLAN CHECK FEE NOPC .
OR' t-Li"•�I
ENGINES]
' LIC.No.(' SIGNS TRANS. - 3.00 1
ARCH.OP ENG �,,y �, PERMI AIfBJ ON
ADO.Vas �'$'3 LDl.[��..�1(]L,�,.�f 1�1-•-� SPECIAL CIRCUIT' _ 5.00 1/AN.1.0
Mr1985
v w� EMP.METER OR POLE INS. 15.00 S MOTORS E FEE SCH'.AODRESSSERVICE CHANGE 10.00o o LICIiNSIiU CONTRACTORS DECLARATIONu 0 1 he'ehy'.07on that 1 am licensed under provisions'of Chapter9y. (commencin with Section 7000)of Division 3 ofthe Businessand ISSTE
e 'BLDG. ELECT. PLG. MECH.
'F w z Professions Code,a m license is in full force t d ff/.yy6tv ❑ - ❑ - ❑
Z o w - License Class_/6_/-Lia Number_ 1.rJ-7 -
wF w Dalc_$c_2-_g!I Contractor .
a m s BUILDING PER
W u
OWNER-BUILDER DECLAItA1'ION - INFORMATION
Oa MISC.- REFER TO ORD
La ; LL N I hereby nolle that I am exempt from the Contractor's Pr License VALUATION $/FT.
Fuoa, Law for the following reason.(Sec.7031.5,Businessand Professions - PERMIT ISSUANCE 6.00 --�
Code:Any Cityintemanty which requiresa Permit to ecrstrum alter, q /^aO r•..
ar improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. / oLJ V
O a, requires the applicant for such Permit to file a signed statement that ' TOTAL PERMIT TO
a w m"' he is licensed pursuant to the provisions of the Contr ctor'%License _
rzQ
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe. OFFirce- 81.-36j-
Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ r,o the'bisis for the alleged exemption.Any violation ofSeclion 7031.5 STORIES - TYPE CONSTR.
aim by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00 q
of not more than five hundred dollars($500).): . .'h V
0 I,as owner of lite property,or my employees with wages as BACK FLOW PROTECT.DEVICE
their sole compensation,will do the work,and the structure is not 2.00 OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contra cior's License Law does not apply to an owner of ..
.•� pruperty who builds or armrovcs thereon,and who does such stark FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA . TOTAL ACREAGE
himself or through his own employees,provided that'sud,improve-
ParrisParris are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improverm nt is sold'veithin one year of completion,lbe owner. GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or am.
Prove forpurposecfsale.). INDUSTRIAL WASTE INTER. 20.00 - RES IND CON PB Other
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
dwensed contractors to Carnslrud the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5.V.B. 5.00 ASSESSORS PARCEL NO.
'and Professions Code: flat Contractor's License Law does not apply
- to an'owner of property who builds or improves thereon,and whoLAWN SPRINKLERS-OVER 5 (EA.) 1.00 7�/7
I conoras for such projects with a conlraclmfs)licensed pursuant to
the Contractor's license Law. SEWER-SANIT RM 'EA.200ft/8.00 TRACTNO. P CEL NO.
•❑ I ant exempt under Sec BAP.C.for this yy ERH ER
T 4.00 "
-1� Rawti
/• owner Date- R SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKFRS'COMPENSA'I ION DECLARATION YPATtR TREATING EQUIP. 4.00
I bcrchy affirm IhaDI have a certificalu of consent io self-insure, ZONING , ENG.BITE N0.
'or a ecrtilicnlc of Workers'Compensation]as ran C.or o cert f,
copy Ihercof(Sec 3800;Lab.C.). -
Policy No. Come'nY 1-4 p.7eF-1 .tf S�'.f_FG •' .
O C,Certified eopy is h eby funushecE - .FIRE SPRINK' ENERGY T-24,
Z Z C ,Cmtified copy filed witlr E E The xfion division.
O APPlicam ��E-.•ter �.•�=.+-.+S• MISC.- .. RTO ORD. Y❑, N❑ Y ❑ N❑
~ rn MIT ISSU CE 6.00 '
CIiR1'IFICCOMOI°SA 6ON INS FROM WORK ERS' Fk000 ZONE A.L.u.c.
OJ _ COMI'F.NSA'1'ION INSURANCE: PLG.CONT uC.N PLG.
CL (This section need nal he completed if the permit is far one TOTAL "'Y❑ N❑ Y ❑' N❑
0,Z hundred dollars IS 100)or less.) -
U'O ' 1 certify that in the"Performance of thr work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
H mitis issued, I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California:
� i Date Applicant ALTER OR ADD TO MECH. ' 4.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of lax- _
H.Z caption,you should become subject to lite Workers'Compensation APPLIANCE - 4.00 PLAN CHECK
Provisions of the Lidma, Code, you must forthwith comply with - FEE
U" such provisions or this permit shall be deenmd revoked.- AIR HANDLING UNIT(TO 10=CF.M.1 3.00
' - CONSTRUCTION LEN DING AGENCY. AIR HANDLING UNIT(OVER 10=CF.M.) 5.00 SEISMIC FEE 7V
I bereiry'ofit,. that Were is a canstroctlub lending agency for EXHAUST HOOD(WITH DUCT) 2.00
;the performance of the work for which this permit is issued(Sec. MICROFILM
•`' 1309],Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00 /
hander's Name HEATING UNIT(OVER.100,000 B.T.U.)7.50 �l.
Lenders Address ELECTRIC
I cerlify that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
t Infoor
rmation is correct. I agree to comply with all city and county BOILERPLUMBING
;�- ordinances and state laws relating to budding construction, and -COMP(3 H:P.OL-1 OO,0008.T.U.) 4.00
hereby authorize representatives or this city to enter upon the BOILER-COMP IGVBr 100,000 BTU)BEE FEE SCH. MECHANICAL
above-mentioned,property for inspection purposes.
(We) agree to save, indem ndkeep� unless the City of MISC.- REFER TO ORD.
Cupertino ag''nst li 'lilies,•' dg nts, ca
s 'nd expenees`which CONST.TAX
may in an way rue - sins said C' i consequence of the PERMIT ISSUANCE - 3.00
gratum 1 is i1. - MECH.CONT. LIC.NO. - MECH. pF�
_ TOTAL TOTAL 7I!A
igm ore o Applic it/Contractor Date
OFFICE COPY - /