C6882 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION / PERMIT NUMBER
r'- - BUILDING - APPLICATION & PERMIT / ��
ADDREss
BUILDING-ELECTRICAL-PLUMBING-MECHANI L
O.NER'S PLAN CHECK VALIDATION
NAME Gup�Q'Z•1 WC) GOT M'.)RN k" CITY. ELECTRIC PERMIT FEE
CONTRACTOR'S
NA.EE OUTLETS-SWITCHES-RECEP 5.00/1.00
sil 1 .mC.No. LIGHTING FIXTURES 5.00/1.00
CONTRACTORSp'CJ S / H 1A N NAN S� PPLIANCES-RESIDENTIAL 4.00
ADDRESS
O ANLhA .�3 PHorvE T A PANELS 5.00 DATE OF APPLICATION '
ARCHITECT /l'iQp M N Q SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OONGINEER\ 1 ` ZMPtiIJ
AM LIC NO. SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
aB00 v ��uss � �
� X C� IIP EMP.METER OR POLE INS. 15.00
ADDREss Ts r4�Q'Q1MJ(�. MOTORS SEE FEE SCH.
c�^ 1 W'
\+JO .Ck. O SERVICE CHANGE 10.00
o o LICIiNSED CONTRACTORS DECLARATION
v 1 herchy affirm'thut 1 am licensed ander provisions of Chupler 9 ISSUANCE DATE
w a N (commencing wish Section 7000)of Division 3 ol't,e Business and BLDG. ELECT I PLG. FOR,
H m z Professions Code and my license is in full Room and effect
Z
o hicensc Class Lic.Number I I I to AC
o z r O Date.- _ Contractor?R1 C.TZ'✓1 - _
¢ r i BUILDING PERMIT
¢ w ¢ OWNER-BUILDER UECLARA'I ION INFORMATION
oa ° MISC.- REFER TO ORD
K
3 LL I hereby affirm that I um exempt Imm the Contractor's Liccnsc
F LL o a Law for the following reason.(Sec 7031.5,Busicessand Professions PERMIT ISSUANCE 6.00 V^LUATION SOFT.
Code'.Any city or county which requires a permit to construct,alter, 9� 00c)¢ ¢ ¢ 2 improve,demolish,or repauaae.aLIC.
Decor any structure,prior 10 its issclso ELEC.CONTR. NO. ELEC. K
- g, requires the applicant for such permit to file a signed statemmnt that TOTAL PERMIT TO
Is
m ti he is licensed pursuant to the provisions of the Contractor's License
� Z I Law(Chapter9(commencing with Section 7000)of Division 3 ofthe GOrig1 QV C T
¢o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE C,IAr>t:,n l Ix
F i
¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
ar
ate _' by any applicant for a permit subjects the applicant For civil penalty ALTER-DRAIN -WATER IEA.) 4.00
of not more than five hundred dollars(5500).): I (x(\(`�•'(��,
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 Dcc.GROUP RES.UNITS
sole compensation,will do the work,and lire structure is not
intended or offered for sale (Scc. 7044, Business and.Professions DRAINS-FLOOR,ROOF,AREA,COND. 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 In,Prove- _
menu are nod Intended or offered for sale.If.however,the budding GAS-EA.SVSTEM-1 4.00 ' ell,
Or improvement is sola within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 ^, Iw BUILDING USE'
builder will ImyCpurpose
the burden Of proving that he did not build or ice- RES IND CO s P9 Omer
prove 1,as
of the p - INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ��1❑ ❑
❑ d as owner of the property,and exclusively. 7044,lbu with
licensed contractors m iConstructe the project(Sea 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 Assessoas PARCEL No.
and Professions Code: ty who
buildsContractor's License Law does not apply r,�Oi b
10 tar Owner of properly who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
Il t Lt f and projects witb'a cnntrvdnr(s)licensed pursuant to
Ile,Lo tr. aoaL s L'w. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT No � PARCELNO.
❑ I xcmpl under Scc. B.&P C.for this
rqaVm WATER HEATER W/VENT 4.00
Is
OwnerDate WATER SYSTEM 4.00 ACC.DATE ACC.FILE.NO,
WORK G RS'COMPBNSA'f ION DECLARATION WATER TREATING EQUIP. - 4.00
1 herchy affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
certificate of Workers'Compensation Insurance.Ora certified
0.� copy thereof(f$$�.���gg����3 x�,0,0,LSI,C .
I'd Noey-!33 ifflliany
CI Certified copy is herchyfurnisled. - FIRESPRINK ENERGY T-24
Z Z .
Cert icd 'opy ix Oled idh the city inspection division MISC.- REFER TO ORD.
CNs ApphcantJ41 FrTLYs�rt/S tfG Y ❑ III E) Y ❑ N❑
OC y ' CERTIFICA"N OF EXEMPTION FROM WORKERSPERMIT ISSUANCE 6.00 FLOOD ZONE A L.0 C.
LU > CONI PENSATION INSURANCE PLG.CONTR. I NO. PLG. ':.,4
CL O (This .,firm need not be completed if the permit is for enc TOTAL Y❑ NI Y ❑. N❑
:) Z hundred dollars Is 100)or less.)
U O 1 certify that in the performance of the work for which this per, CITY. MECHANICAL PERMIT FEE FEE SUMMARY '
LL F mil is issued, I shall not employ any person in any mannerso as to
U become subject to tie Workers'Compensation Laws Of California. A-/
O ED Date Applicant ALTER OR ADD TO MECH. 4-00 BUILDING O Fs.
} m
NOTICE 'I'O APPLICAN"C If,after conking this Certificate of Ex-
Z emption,you should beconm subject to the Worker Compensation APPLIANCE 4.00 -"PLAN CHECK 7
provisions of the Labor Code, you most forthwith comply with f
U such provisions or this permit Shall he deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00 FEE f
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10SWC.F.M.) 5.00 SEISMIC FEE _
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the perfommnce of the work for which this permit is issued(Sec MICROFILM
3097,CIv.C.). 1 RxuA HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Noma HEATING Lender's Addre �M� C"A'vse�� C �` UNIT(OVER 100,0008.T.U.)7.50 ELECTRIC
1 certify that I have read this application and stale that tie above VENTILATION FAN (SINGLE) 3.00
informationis uvrcd. I agree
a to Comply with all city and county PLUMBING
ordinances and state laws elating to building construction, and BOILER-COMP(3H.P.or100,000B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) ago. 10 save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in.consequence of the PERMIT ISSUANCE 3.00 v
granting of this Permit MECH.CONT. LIG NO. MECH.
,e '.�QC�R� ,JIAdRS TOTAL TOTAL
Sign urea pp and/Co trmnor al
INSPECTOR COPY