C6794 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -. USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENT]FICATI ON ,t PERMIT NUMBER
ADDRESS APPLICATION & PERMIT // Iv�- 6794
ADDRESS
717 A r- BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE 2^\)
y PHON 5 �.J ////]�}/�f
CON RACTOH'S Y
NAME 'j OUTLETS-SWITCHES-RECEP 5.00/1.00
/o LID.No.J LIGHTING FIXTURES 5.00/1.00
CONTRACTORS - APPLIANCES-RESIDENTIAL 4.00
A O DR ESS
'HONE PANELS 5.00 DATE OF APPLICATION
ORRCRITECT ; SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
AATCH.OR
DDRESS ENG, SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH. 1...
ADDRESS
SERVICE CHANGE 10.00 /
w at t hICIiNSIiDCON'I'RACTORS DECLARATION 4
a o U I hereby affirm that I am licensed under protm...is mf Clwpler 9 ISSUANCE GATE
v~i< m (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F w z Professions Code,and my license is in full fort-m d effect. ❑ ❑ ❑ ❑
z O,A- License Class I'f of 4 Lie.Number V S _]
w I-
Date z���r Contractor /r U o Mnf`f 1
a a s BUILDING PERMIT
¢ ¢ w a OWNER-BUILDER DECLARATION INFORMATION
o a MISC.- REFER TO ORD
X a w I hereby aft ilo i11,ng I am exempt lio.5 the Contractor's License VALUATION $/FT.
j law for the following mason.(Sec.703 L5,tlusiness ane"Dofes,mm, PERMIT ISSUANCE 6.00
Code:Any city orcounly which requbesa permit tomintme Latter,
¢ ¢ Q p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTH. LIC.NO. ELEC.
p ¢ re9uires the applicant lam such permit In file a signed statement that TOTAL PERMIT TO
a w m y he is licensed pursuant to the provisions of the Contractor's license L9' C
F z I Law(Chapter 9(commencing with Section 7000)o'Division 3 of the �U' � J sr 7'a---1
- G Ilusiness and Professions Code)or Ilial he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r p the basis for the alleged exemption.Any violation of Sectiou 7031.5 1 STORIES T TYPE CONSTR.
u ; w by any applicant for a permit subject,fit,applic.ol Wa civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(S500LL
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 2.00 Oce.caouP RES.urvlTs
their vole compensation,will do the work,and the structure is not -
intended or offered for sole (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
(ode:The Contractors License Law does not apply to an owner of
property who builds OF improves thereon,and who does such work FIXTURES-PER TRAP 4.00 sa FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- .
mems 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-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or ini-
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB Omer
O 1,as owner,of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors In construct ole project(Sec.7144,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:l'he Contractor's License.Law does not apply '
It,
un owner of property who builds or improve,thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
onntracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. - SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec ,B.&P.C.for this WATER HEATER W/VENT 4,00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILENO.
WORK ERS'COMPENSA'I ION DECLARATION WATER TREATING EQUIP- 4.00 U'
I hereby at0rm that I have a certifwateofconseni Ioself-insure. S f
ZONING
or i certificate of Workers'Compunsalion Insurance,or a certified ENG.SITE NO.
copy thereof(Sea 3900,Iab,C.).
Policy No.-611.'1,-Co tf�yI'++Yn]�4
O ❑ Cert ilicd copy is l�•rY Furnlshcd. ibel-t Y dl FIRE SPRINK ENERGY T 24
Z Z. -`yylt Certil ieA 'opY is filed wiph the 4 y inspe Hon division.
O AISplicam -1C /// - / MISC.- REFER TO ORD. v❑ ry❑ Y ❑ N❑
oto CER"I'119CA1E 01:EXFMPI ION FROM WORKERS' PERMIT ISSUANCE 6.00 U1 FLOOD ZONE A.L.UC.
W COIVPISNSATION INSURANCE PLG.CONTR. LIC.NO.
d ❑ (This section need not be completed,if the permit is for one TOPLG.TAL r� Y❑ N❑ Y❑ N❑
::) Z hundred dollars(SIOEI less.)
U O 1 certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
O w becomes bbcl Io Phu A"it s'Co ensation,I 4 s f Culifomia.
Date 1 I cant A/- w BUILDING `rD S.L
a - -' pP i" 9 ( �Cf6�(. ALTER OR ADD TO MECH. 4.00
} N NUl'1,li O ITL ICAN'I': ll,u t mu g thn Ccrt fmalc of Bx- �-
F_ Z cniptim,you should beams,subject In the Workcrs Compensmmu 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 10SMC.F.M0 3.00
C'ONSTRUCI'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby uflimh that thea is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
T 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
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that l havercad thisapphemim,aEdsbib,that the above VENTILATION FAN (SINGLE) 3.00 Till
h information is correct. I agree to comply with all city and county PLUMBING
ordinances and slate Iaws relating In building construction, and BOILER-ODMP(3 H.P.or 100,000 B.T.U.) 4.00 V
hereby authorize representatives oC this city to enlvr upon the BOILER-COMP (Over 100,0o0BTU)SEE FEESCH. MECHANICAL
above-mentioned property Inn inxpeetion 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 way accrue against said City in consequence of the
granting of this pe�ry L MECH.CONT. LIC.NO. MECH.
�VA* X�& �, ,- �f{ TOTAL TOTAL (o ff
SlgnaTre of Applicant/Contractor Date (J/
INSPECTOR COPY r
i