18680 (3) APPLICANT TO FILLIN INFORMATION WITHIN RED LINES - USE BALL POINT PEN OPILY
BU I LDING PROJECT I DENTIFICATI ON 11, PERMIT NUMBER
BUL s $Ni4t� F.i�s., fli�0 (JIB APPLICATION & PERMIT O
ADDR E55
Hi�iDJ BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
OwNE R'S PLAN CHECK VALIDATION
""M'El�ti)J;SNEMLS (i('961 OTV. ELECTRIC PERMIT FEE
PHONE -
CONTRACTORS
/ NAME •7 OUTLETS-SWITCHES RECEP 10.00/1.00
MCO , tj 6 ' CO LIC.0, 3 1 LIGHTING FIXTURES 10.00/1.00
CONTRACTOR 60 U APPLIANCES-RESIDENTIAL 4.00
e,A1_P ,41X22 , O /f PANELS 10.06 DATE OF APPLICATION
ARCHITECT
OR PANELS (OVER 200 AMP) 26,66 PLAN CHECK FEE P.C.N0.
ENGINEER
uc.NO SIGNSTRANS. '
ARCH.OR ENG. - SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS r
-' ZIP EMP.METER OR POLE INS. 20.00
ADDRESS /l./ JGI_ 1
APPLICANT'S G� • ITnIeJ�i�jl7 MOTORS SEE FEE SCH. Y\'
' �/�C, 111
SERVICE CHANGE 20.00
r o O LICENSED CONTRACTORS DECLARATION
a V u, I hereby afhrn that I am licensed under provisions of Chapter 9 OUr I ISSUANCE DATE
y a a (commencing with Section 70001 of Division 3 rl the Business and BLDG. E\ECT. 'PLG. MECH,
w• w i "note
Codc,and my li ease is in full for •and cffrc.
z o - License Class.( Wic.Number �- �E�j[1 ^ fy J']p ❑ ❑ ❑
Q r w
Date� /� Commcmr_ vov Y N 9 d J
JBUILDING PERMIT
E , W u OWNIi R-BUILDER UECLA RATIO INFORMATION
w3 LL I hereby allium that I am exempt from the Comma.",License MISC.- REFER TO ORD
.. o j Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00 - vAwnn Ory S/FT.
- Code:Any city or county which requires.permit toc...to-M altel,
Ra,Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. Tut Ul/
are
O ar squires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
wm o he is licensed pursuant to the provisions of the Contractor's License
FZV, Law(Chapter 9(eonrmencing with Section 7000)ofDivision 3 of the
Business and PollesslCode)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
om
ar I_o lire basis for the alleged exemption Any violation of Section 7031.$ 1 STORIES TYPE CONSTR.
nom _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($5000:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole Compensation,will do the work,and if,,structure is nal OCC.GROUP RES.UNITS
intend,d or ofi'ercd for sale (Sec. 7044. Business and Por l'essions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code.The Contractor's License Law does not apply to an owner Of
property will)[)units or Improves thercon,and who does such work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or cut
bde ownemployees,for sale.
If,
however,Devi mail improve- GAS-EA.SYSTEM-11NC:40UTLETS 6.00
muss arc not inter des ornempl ee sale.If,ed thatthe building
r improvement is sold within or,,year of completion, the owner GAS EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving tlrat ha did not build or ins- RES IND CON PB Other
prove for Purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
0 1,as owner of the property',am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and I'r^I'essions Code:l'he Contractor's License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contmctor(e)licensed pursuant to
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT N0. PARCEL NO.
❑ lam exempt under Sec. .B.hP.C.for mis WATER HEATERW/VENT 6.00
non
Owner Date WATER SYSTEM 5.00
ACC.DATE ACG FILE N0.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate it Workers'Cmy�p ensatiun Insurance,or a certified
copy thereof)S�ey']80 Lu1�!/'
Policy Ne0r4J(�npah$�_��� �� JrV�4
Q ❑ Certified - y I by I'unnshcd FIRESPRINK ENERGY T 24
Z_ Z SY Ccrtil'i d Y n IilcdivjitY inspection Aivision. MISC.- REFER TO ORD. v N v N
A plicxnr_ Nts�i ❑ ❑ ❑ ❑
GiZj�-- JPERMIT ISSUANCE - 10.00 cLaoD zoNE A.L.u.C.
> CIi R'Il1'ICA'I'C OF FXEMPTION FROM WORKERS'
Lu _ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. v[:] N❑ V ❑' N❑
0. 0 ('Phis xc,Irou need not be completed if the frond is for one TOTAL
D Z hundred dollar,15100)or less,)
U O 1 Certify that in the perhor ian a of the work'or which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued. I shall nor employ any person in any manner so as to r
O L) become subject to rhe Workers'C'ompensarion Laws of Calif oro ma.. BUILDING /oV
Date Applicant ALTER OR ADD TO MECH. 5.00
} N NOTICE'f0 APPLICANT: If,atter making this Certificate of Ex-
? eruption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK L/l-J+dam
provisions of the labor Code, you must forthwith comply with FEE 71S
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10=CF.NL) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE �3
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
30ader97. ',am �O _
fender's Name HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
CM
Lender r Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply'witti all city and county PLUMBING
i ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
' hereby authorize repnescntatives of this city to enter upon the BOILER-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 10.00 CONST.TAX �-
may in any accrue against s City in consequence of lire
grant s Permit. MECH.CONT. LIC.NO. MECH.
r _ TOTAL TOTAL (�]7•_
Sig urcol ) '
pp canttor Uatr
OFFICE COPY