4796 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI_ POINT PEN ONLY
BU LDI NG PROJECT I DENTI FI CATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 4796
ADOREss
( LA dr aNa CIC_ BUILDING -ELECTRICA L-PLUMBING -MECHANICAL
OWNER'S - PLAN CHECK VALIDATION
.NAME J QTY. ELECTRIC PERMIT FEE
�r. �"C�Ie 1�Y1a� PHONE aS5Ia5
cOVTRACTORS OUTLETS-SWITCHES-RECEP 5.00/1.00
NAME , 11 c ao
�J_ tRL11 JC1 LC.No. ` (,5gly LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
ADDRESS �1c�
I ILI5 S.31p57. • S, f.PHONE «O(04 73 PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.0.N0.
OR
ENGINEER
LIC.No, SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00
ASS MOTORS SEE FEE SCR.
ADDRESS
SERVICE CHANGE 10.00
o o LICENSED CONTRACTORS DECLARATION
2 v I hereby affirm that I all,licensed under provisions of Chapter 9 ISSUANCE DATE
y a ic
m (commencing w h Section 7000)of Division 3 of the Business and
F m Z Profession Coe1:yt0i� rnsc is in full forill cBLDG. ELECT. PLG. ME
rulNecp�L ❑ ❑ ❑
z o m- I.icense Clac Lic.Number
o Z F O Dale-Contractor_A, (�
a y s BUILDING PERMIT/
¢ ¢ w ¢ OWNER-BUILDER DECLARATION INFORMATION
¢ 0 "
w ALiMISC.- REFER TO ORD
L_ I hereby affirm that 1 am exempt from the Contractor's cense
uoa Law for the following reason.(Sec.7031,5,Rusiness'•md Professions PERMIT ISSUANCE VALUATION S/FT.
� - Code:Any city orcommy which reyuiresa permit to construct.alter, 6.00
BER ¢ 20 improve,denwlish,or repair any structure,prior to its issuance,alsoELEC CONTE. LIC.NO. ELEC.
G¢ requires the applicant for such penuit to file a signed statement(hat TOTAL pe ERROR TO
d w m" he is licensed pursuant to the provisions of the Contractor's 3 jicnxe / v/
FzA Business
ndprocosions Cngwi lh Section is exemfttheon3ofthe 'V1/
F i 0 Business and he alleged a empt or that he is pt Section 0 and CITV. PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption.Any violation of Seclion007 1,5 STORIES TYPE CONSTR.
Laim by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars 1S500).1'.
❑ L as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP - RES.UNITS
their sole contpensmion,will do the work.and the structure is not
intended or offered for sale(Sec. 7044. Business and Prot csstons DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.ET.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided than inch I P,ove-
11,are not intended or offered for sale If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
Lr Improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB Other
❑ 1,as owner of the pro perry,ant exclusively'contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
Bud Professions Code:The Contractor's License Law dues not apply
to an owner of property who builds or improves thereon.and who LAWN $PR INKLERS-OVER 5(EA.) 1.00
contnusts to'
m'it projects will a contractorts)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ tum exempt under Sea ,li.&1'.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC FILE NO
WORK FRS'COMPENSA'HON DECLARATION WATER TREATING EQUIP, 4.00
I herebv affirm that 1 have u certificate of LORSGIII to s hLinsam, ZONING ENG.SITE N0.
or a certificate f Worker Compensation Insurance:or a ecI.i�^^'
copy theft eh3 b 6 Qui FCQ CLU'd
g0 T
[',,If N 'Co'fibally-��
Q ❑ Certilied cop)'is hereby'funtisx'd.. FIRE SPRINK ENERGY T-24
yCerrfica 'opy is Ileo wish the cry inspections division. MISC.- REFER TO ORD.Z
p Apphcanl-Rb-/-r .n ,je(t�- ��,-=S-�J v ❑ N❑ v ❑ N❑
CC h CER'IIFICA'I'Ii OP EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC NO. PLG.
CL O 1'l his section ties(] not be completed if the penuit is for one TOTAL Y❑ N❑ I Y ❑ N❑
Z) Z hundred dollar,(SIO0l or less.)
U O 1 certify (flat in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any manner so as to
U beconm subject to the Worker,'Compemation Lows of Calilcmin.
Ed Dale Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} to
NO]107.TO APPLICANT: IL odor making this Certificate of Ilx-
H z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the 1-abor Code, you Insist orthwith 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=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 I'or which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 (� MICROFILM
3097,Civ.CJ, .Q
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I 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
names and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
authorise representatives of this city to emcr upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
,.,mw,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 can
Ux se
Pene which p CONST.TAX
may in any way accrue against said City in consequence of tile PERMIT ISSUANCE 3.00
e 3•ua
Virg ot Iltis l!xn... MECH.CONT. LIC.NO. MECH,
tla�k9 ! ?:qz- 85- OTA Jd TOTAL
Signature of Applicant/Conmmtor Dao
INSPECTOR COPY