1265 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMITN R
BUILDIND APPLICATION & PERMIT 1265
Y., ADDRESS _
/�iPTOE" z'4 A, BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
x--sIEMER/SJ��('h h$ Hf'a �/JQ - - 'w1^ , y1T - - PLAN CHECK VALIDATION
CITY. - "ELECTRIC PERIII.' FEE"
-
CONTRACTORs UTLETS-SWITCHES-RECEP 5.00/1.00
NAME
LIC.No. ILIGHTING FIXTURES 5.00/1.00
CONTRACTORS APPLIANCES
PHONE
4.00
AODR ESS
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECTSIGNS Fj-DD
.ENGINEER PLAN CHECK FEE P.C.NO.
OR
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
n 1s'
02 LICENSED CONTRACTORS DECLARATION My OF ri--.hctnT�
M u u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
N< w (commencing with Section 7000)of Division 3 of the Businessand BLDG. ELECT. PLG. MECH.
H D i Professions Code,and my license is in full force and effect.
NOV ❑ ❑ ❑
z O - License Class Lic.Number
2 v, H W Date Contractor
a Y @ 'cs a',BLIILDINMPERMIT=?4����'"
rc m LL ¢ OWNER-BUILDER DECLARATION s OIN FORMATIONc*?'{
WO - r 1 hereby affirm that I am exempt from the Contractor's License MISC.- ER TO ORD 11•t^'S
3 y Y p VALUATION S/FT.'
0< Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct.alter,
fe a ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- DLL requires the applicant for such permit to file a signed Statement that TOTAL PERMIT TO
w$ he is licensed pursuant to the provisions of the Contractor's License _
F i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe fie, a"A"n •+At. r
¢ Business ant.Professions Code+or that he is exempt therefrom and GTIY II d PLUMBING'PERMIT4 .t T FEEkl
¢ LLQ the basis for the alleged exemption.Any violation of Section 70315 "s� *�'A.i!La �K.,�. 'F':Y.'S art+•vxye+.�M - ' fit STORIES TYPE CONSTR.
i ; _ by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN -WATER (EA.) 4.00
effort more than five hundred dollars(55001.1:
❑ 1,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 far sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,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 F IXTUR ES-PER TRAP 4.00 So.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,Provided that such improve-
menH arc not inch his or employeeffered for.provided
howeved that such
he building GAS-EA.SV$TEM-1 1NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND LOG PB Omar
for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ 1:1 E]❑ I,as owner of the property,am 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 Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY•STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
- ❑ Ism exep/pu*f,Sec. .B.&P.C.for this WATER HEATER W/VENT 4.00
reason !Y C Y'
Date f,- I Owner _.._._ WATER SYSTEM 4.00 ACC.DATE ACL.FILE NO.
WORKERS'COMPENSATION D17CLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that 1 have a certificate ofconsent to selLinsure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance.or a certified
copy thereof(See.3800.Lab.C.l.
Policy Na. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
z Z ❑ Certified copy is filed with the city inspection division.- MISC.- REFER TO ORD.
O Applicant Y❑ N❑ I Y ❑ N❑
H CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
IL > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. pLG.
a. o (This section need not be completed if the permit is for one TOTAL V❑ N❑ V❑ N❑
=) 2 hundred dollars(SI00)or No.) y-. '. "•': -a => - ", •' t r•r-;-{i'
U O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE' '_FEE SUMMARY tit'.*h'it
LL F mit is issued, I shall not employ any person in any manner so as to -.
U becomesubject to the Worker:Compensation Laws of Califomia. /Q 00
ad Date Applicant ALTER OR ADD TO MECH400 BUILDING
} N NOTICE TO APPLICANT: If,after making chis Certificate of Ex-
. .
Fz 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 b `�
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000QF.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
Lenders Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I Certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
information n correct. I agree to comply with all city ucti county PLUMBING
ordinances and state laws relating 10 building l city and coction, andmy BOILER-COMP,13 H.P.or 100,000 B.T.U.) 4.00
hereby autharite representatives of this city to enter upon the BOILER-COMP (Over 100,000BTUI SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agag to save, indemnify and keep harmless the City at MISC.- REFER TO ORD.
Cupertino test a b'"'e"
judgments, costs and expenses which CONST.TAX
may in way Ii,
a incl ser d City in consequence of the PERMIT ISSUANCE 3.00
gran ' Of this pe tryt. MECH.CONT. LIC.NO. MECH.
TOTAL
Signature of Applicant/Contractor Date
OFFICE COPY