6793 (3) _ 4r
APPLICANT TO FILL IN INFORM,/TION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRES 0 '6L2iwmo AVP BUILDING -ELECTRICAL-PLUMBING-MECHANICA
N793
OWNER'5 P AVALIDATION
• NAME III to US e_ PHON S CITY. ELECTRIC PERMIT-` FEE 2-
^ n
CONTRACTORS �'1 UTLETS
-SWITCHES-RECEP 5.0011-00 /
NAME 2S y
if r UYjI f I C L.C. 765. LIGHTING FIXTURES 5.00/1.00.
ADDSCONTRACTOR's PPLIANCES-RESIDENTIAL 4.00
ADDREss
9JPHONEV71-OWPANELS .17 5.00 DATE OF APPLICATION
ARCHI E T ISIGNS - 6.00 -7
LAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC,No, SIGNS TRANS. - 3.00
ARCH.OF ENG. �� SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADD
REss
ZIP EMP.METER OR POLE INS- 15.00
ADDREss TS MOTORS _ SEE FEE SCH.
SERVICE CHANGE 10.00 "r' /•.sem
0 0 LICENSIiD CONI RACTORS DECLARATION •`. _
a u v I hereby air nn that 1 am licensed under provisions of Chapter 9 •+7 ISSUANCE GATE v
y a$wi (commencing with Section 7000)of Division 3 of the Business anJ B ELECT. PLG. MECH.
H N z lf.frssmns Code nd nI license is in full fore and rffre. �? ❑ ❑ ❑
z o w - License Clayyyyyy������ Lic.Number
a z F 0 1)atc�/,( Contractor_ y c n S• j r�
BUILDING PERMIT
¢ ¢w ¢ OW'NIi R-BUILDER DECLARATION 6 INFORMATION
a o a ca MISC.- REFER TO ORD
w3 a r I hereby affirm that I am exempt from the Conlrand Pric LicanvCe
a 0 j Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE VALUATION 5/FT.
- Code:An R or county which re uiresa permit toconstruct alter, 6.00 ,S
EE ¢ 0 improve,demolish.or repair any structure,prior to its issuance,also ELEC.CONFER, LIC.N0. ELEC. IT w
0¢ requires the applicant for such permit to file a signed statement Ilial TOTAL PERMIT TO
a w m a he is licensed pursuant to the provisions of the Contr:etor.'s License �l
Uzi
Law(Chapter 9(commencing with Section 7000)of Division 3 of the \NA
m o Ifusiness and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE aa.�IX. dlIn
¢ F o the basis lox the alleged exemption.Any violation o(Seclion 7031.5 STORIES YP CONSTR.
ta 3:a - by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than fisc hundred dollars($500).):,6".
❑ I,as owner of the Property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCG GROUP RES.UNITS
their solo compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Curie:The Contractor's License Law does not apply to an owner m,
properly who builds or improves thereoh!and who docs such work F IXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTALACREAGE
• himself or through his own employees,provided that such improve. _
ments are not intended or offered for''sale.It,however,the building GAS-EA.SYSTEM-1INC.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 pmirg that lie did not build or im-
provefor purpose.1sale.). - INDUSTRIAL WASTE INTER. 20.00 RS IND CON PB Omer
Cl 1,as owner of the properly,am exclusively contracting with EIEl ❑ El
licensed contractors to con��l1��ucl the project(Sec.7144,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PAR CE LNG.
and Professions Code:"fhea(ISntrudor's License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPR IN KLERS-OVER 5(EA.) 1.00
contratine Contractor',
fctor',License
with acontractorlsl licensed pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
the tracts for
S s License L.W.
❑ I ann exempt under Sec. .B.&P.C.for tills WATER HEATER W/VENT q,Op
reason
Owner - Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
• WORK ERS'COMPENSATION DECLARATION' WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to selt-lnsne. ZONING
or a ceDillcule of Workers'Compensationra
Insunce,or a ttrlified ENG.SITENO.
copy Thereof(Sec,3800,Lab.C.).
Policy No.UfC�_Company 4 1-n
.O ❑ Certified copy is hcrcby lunnishctl. /l rf ( ��� FIRE SPRINK ENERGY T"24
Z Z CerlificJ copy ix BIcA with the city mine n rvlMo
O R pGc:nit MISC.- SC7 jar REFER TO ORD. Y❑ N❑ Y ❑ N❑
O� to CIi R'fl 1. Axl*]-OP EXEMPT ION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU >_ '(OS1I'IiNSA[ION INSURANCE PLG.CONTE, LIC.No. PLG. D�-
OTAL N N
CL D z (Phis sort' R need nal be completed it the permit is for one ❑• ❑ ❑ ❑
Z humdreddo rp IS IUOI or less.I
U O 1 vend' at in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL'l- our is is id.1 shall not unploy aIy'{ O n in any manner so as to
become sob'cct (the Workers inion La fCah' rnm.
0 a Uan_�i Applicant � �Let s - ALTER OR ADD TO MECH. 4.00 BUILDING S�
} W NO "I 1 i ICANT: IC of c ma ing til s ern to 3x-
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions m this pernit shall be deemed revoked. AIR HANDLING UNIT(TO 10A00C.F.M.) 3.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of do work for which this permit is issued(Sec. - MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Nam. H EATI NG UN IT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I here read this application andstate that me above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and stud: laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hcrcby authorize represenlatives 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 CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
granting of this permit MECH.CONT. LIC.NO. MECH. Al
f TOTAL TOTAL
Signaluseo Applicant/Conractor [e
.I 'INSf3ECTOR COPY - ,