5298 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
ADAPPLICATION & PERMIT 5298
ADDRESS
0;)
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAMEQTY. ELECTRIC PERMIT FEE
PHONE
NAME
c RST '/�'(� R OUTLETS-SWITCHES-RECEP 5.00/1.00 �
Y� LIc.No, Q LIGHTING FIXTURES 5.00/1.00
r, NrRAcroR's C]r a„•, C q� ppLI ANCES-RESIDENTIAL 4.00
ADDRESS Oz+ R
r4HONE PANELS 5.60 S DATE OF APPLICATION
OR
X67-3313 SIGNS 6,00 PLAN CHECK FEE P.C.NO.
ENGINEER
W. SOL. uc.rvo. SIGNS TRANS. 3.00
PERMIT VALIDATION
ADDR.SS Nc' SPECIALCIRCUIT 5.00
'
ADDRESS
L- f-Fzm 1*11, EMP.METER OR POLE INS. 15.00
PPL cnrvrs�gL-A I K `�f_/,�� MOTORS rf (� SEE FEE SCH. 3 l A J
ADDRESS (r'f� (X/[
JIMyty� SERVICE CHANGE 10.00
00 LICENSED CONT RACTORS D17CLARATION
a U v hereby ufl irin that I :un licensed under provisions of Chap[er'I - ISSUANCE DATE
m < (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
Wir
w z I'ral'llome,Code,:m I n licinse is in full force'
z o m - License Class_ f �16 1 Lic.Number 3,
Q z 0 1) l 1Q_ I C,nntruchn--p /
Q y f t I BUILDING PERMIT
w a OWNER-BUILDER DECLARATION INFORMATION
w ° aI hereby Alvin that 1/ant exempt from the Contractors License MISC.- REFER TO ORD
3 u VALUATION $/FT.
Fw0JLaw for the hdlowingjeason.(Sec.7031.5.Businessmid Professions PERMIT ISSUANCE 6.00 ,
Code Anycityorcountywhichrequiresapermitto construct,alleq -
Q0 improve,demolish,or repair any structure,prior to its issuance,also .ELEC.CONTR. LIC.N0. ELEC. /
°LL requines the.,,,heart for,uch permll to file'a zigne(1 statement that TOTAL 1O I PERMIT TO
a w m he is licensed pursuant Iridic provisions ofthe Contractor's License
Luw(Chapter9(comriencing with Section 7000)of Division 3 of the '671 C
Itusiness and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE /
¢ H o the basis for the alleged exemption.Any violation of Semion 7031.5 STORIES TYPE CONSTR.
n 5,: by any applicant for a permit subjects the applicant to a civil Penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
of not more than five hundred dollars(S500).L
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractors 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.FLDDR AREA r0TALACREAGE
• himself or through his own employees,provided that such improve-
rechsare not intended oroffered 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 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or am- RES IND CON PB Omer
prove for purpose ol'saleL. INDUSTRIAL WASTE INTER. 20.00
D 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 ASSESSORS PARCEL NO.
and Professions Code:'I'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 project,with a contractors)licensed pursuant to
ate Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
rL❑no
I and exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 4.00 v`
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORKIIRS'COMI'I!NSA'I'ION DECLARAI'ION WATER TREATING EQUIP. 4.00
1 hereby attirnl thol I have a cerlileate of consent to self-insure. ZONING ENG.SITE NO.
or a certi(icam of Workers'Cumpens'ul I suruncu,or a certified
copy thereof(See 3500,Lab C.).
Piney Nn. Company-
0' Z'Y•(:erlin, 1 c by)'urn-hcd. • FIRE SPRINK ENERGY TQ4
ZZ 'Cer' '1 with�ff caion division. -
O A plica a C MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
2 to Ci RTI 1:1C 117,OF E%EM Rf 10N FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
I W 1 CONIPENSAITON INSURANCE PLG.CONTR. LIC.NO. PLG.
�' (This section need not be completed if the permit is for one TOTAL V❑ N❑ Y❑ N❑
Z) Z It u timed dollars IS 100)or less./
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not enti loy any person in any manner so as to
U become Subject to the Workers Compensation Laws of California.
a Date Appli°antALTER OR ADD TO MECH. 4.00 BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of lix-
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
CONSTRUCT ION 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 pernin is issued(Sec. MICROFILM
3097,Civ.C.), HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEAGU IT(OVER100,000B.T.U.)7.50 ELECTRIC
Lender's Address
I certify Ute I have read this application and state that the above VENTI LATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and coumy PLUMBING
u dinuaces and state laws relating to building construction, anJ BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby mnhod, representatives' of this city Io anter upon the BOILER-COMP (OVOr 100,000 BTU)SEE FEE SCH. MECHANICAL
above mentioned property for inspcc(inn Pur
(We) agree to are, in len inly and p I uml ss the City of MISC.- REFER TO ORD.
Cupertino against liabilities;judgments cuts and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
ncy 'ny wiry accrue agoixt said sty i consaruence of the
gr' t o lsp' if MECH.CONT. LIC.NO. MECH.
OTAL
^ TOTAL
gnature u pp icmrt Contractor Date
INSPECTOR COPY
I