6669 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 6669
ADDRESS
o BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OLNN E •�R'S "'''' ..
PLAN CHECK VALIDATION
NAME .rr,rr' `,r .�y - - -, ;
t<jl"Z � ';�. ;'1rL�CT;RICPERMtI' .-:"
PHON
NA E rolls OUTLETS-SWITCHES-RECEP 5.00/1.00
-J,2,14ZWZA LIC.N �/ LIGHTING FIXTURES 5.00/1.00
C ACTOR'S
ADDR APPLIANCES RESIDENTIAL 4.00
P O �( PANELS 5.00 DATE OF APPLICATION
AARRCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. ISIGNS TRANS. 3.00
AARCH.DDRESS ENG. SPECIAL CIRCUIT 5.0Q PERMIT VALIDATION
-ZIP EMP.METER OR POLE INS. 15.00
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH.
9X
J
SERVICE CHANGE 10.00
0 2 LICENSED CONTRACTORS DECLARATION
¢ Luli c~i I hereby affirm that 1 am licensed under provisions of Chapter 9
a y p s ISSUANCE DATE
Z a (commencing with Section 7000)of Division 3 of toe Business and
N < BLDG. ELECT. PLG. MECH.
F D z Professions Cod d my license is in full fo rectC� ❑ ❑ O
Z0 W o License Clas �Lic.Numbe
_ Z r J Date ContractOV
z ¢ w OWNER-BUILDER DECLARATION
X 0 LL r 1 hereby affirm that I am exempt from the Contractor's License
MISC.- REFER TO ORD 1N1!=OFiAl�tlllTdfl
LL o J Law for the following reason.(Sec.703 1.5,Business and Professions VALUATION $/FT.
y Code:Any city or county which requires a permit to construct,alter, PERMIT ISSUANCE 6.00
¢ e 2O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
nw o ¢ requires the applicant for such permit to file a signed statement that TOTAL
X m N he is licensed pursuant to the provisions of the Contractor's LicenseL Mqu
F Z > Law(Chapter 9(commencing with Section 7000)of Division 3 of the / r
EE o Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE ..
¢ O the basis for the alleged exemption.Any violation of Section 7031.5STAFUG C TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty H VV
of not more than five hundred dollars($500).): ALTER-DRAIN&VENT-WATER (EA.) 4.00
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.et"bf ITS
their sole compensation,will do the work,and the structure is not Vt�J {jp �
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 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 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.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4(EA) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- . - .
RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 1:1 El El 1,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 PAI 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 contractor(s)licensed pursuant to L>
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/ TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec. B.&P.C.for this WATER HEATER W/VENT 4.00 �*P
reason
Owner Date WATER SYSTEM 4,
C.DATE ACC.FILE N0.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 4.00
1 hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ ,eertlfied copy is hereby furnished. FIRE SPRINK ENERGY T-24
z Z �Certified c p is filed it the cityt inspection division.
CC)) ApplicantMISC.- REFER TO ORD. Y [:] N v ❑ N[]
CERTIFICA E OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 0_0 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d 0 (This section need not be completed if the permit is for one TOTAL Y N Y N
D Z hundred dollars(S 100)or less.) yµ
U _O 1 certify that in the performance of the work for which this per- MECHANICAL PERMIT FEE FEIt3VNCIR ~;'`;
LL H mit is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
Date Applicant BUILDING
a pp ALTER OR ADD TO MECH. 4.00
} to 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
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=11C.F.M.) 5.00 SEISMIC FEE
1 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 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
1 certify that 1 have read this application and state 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 I BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOI LER-COMP(Over 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 PERMIT ISSUANCE 3.00 CONST.TAX
may in any,wa accrue against said City in consequence of the
grant�ofermi MECH.CONT. LIC.NO. MECH.
TOTAL 70TAL
Signat of Applicant/Contractor Date
OFFICE COPY