6265 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
N.•
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
APPLICATION & PERMIT
ADDRESS 6265
ADDRESSUILDNO /
OZy-O Blob Q02 BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
QTY. ELECTRIC PERMIT FEE
• /I C C� PHONE -
NAME enols OUTLETS-SWITCHES-RECEP 5.00/1.00
NOJ
5 ,rfor LIGHTING FIXTURES 5.00/1.00
CONTRACTOR s APPLIANCES-RESIDENTIAL 4.00
ADDRESS A1,4
308 5_-z v C�. Al/ PHONE k4- Z PANELS 5-00 DATE OF APPLICATION
ORCHITECrSIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
`'i�Hre uc,NO SIGNS TRANS. 3.00 '
ARCH.OR ENG. SPECIAL CIRCUIT S.00 PERMIT VALIDATION
S
AODRE
ZIP EMP.METER OR POLE INS. 15.00
APPLICANT OMOTORS SEE FEE SCH. J
ADDRE
5Q°`a SERVICE CHANGE 10.00
O o LICENSED CONI'RAC'I'ORS DECLARATION
Q vI hereby affirm that I am licensed under provisions of Chapter 9 - ISSUANCE DATE
y G & (Commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H w z Professions Cnde,and ny license is in full force and effect.
Z o u, license Cla �F6_Lic.Numbe1 7G 7/2 ❑ -�-
9 m Uute 2�/O Contractor S�t�
a m 4 r BUILDING PERMIT
¢ ¢ w4 OWNER-BUILDER DECLARATION INFORMATION
0A " MISC.- REFER TO ORD
X u w I hereby alliin that 1 am exempt from the Contractor's License
w .. 0< Law lot the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE VALUATION $/FT.
Ly Code:Any City orcountywhich requires apermit toconstruct.alter. 6'00 22-7 '7
2 s Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. ,
at
O ¢ lectures the applicant for such permit t0 file a signed Stale 111 cult that TOTAL PERMIT TO
a w he is licensed pursuant to the provisions of the Contractor's License
Hzi
Law(Chapter 9(commencingwith Section 70001ofDivision 3 ofthe
- e Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE -
¢ r p the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
aim• by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER(EA.) 4.00
of not clone than five hundred dollars($500)J:
❑ 1,as owner of the property,or my employees with wages as BACK FLOW 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 Contractor's License Law does not apply to an owner of
pmperty who Imilds or unproves therco ,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 improve-
mentsare not intended orOffered for sale.If,however,the building GAS-EA.SYSTEM-l1NC.40UTLETS 4.00
r ImprovmnaN is sold within one year of completion,lbc owner. GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder,will have ole burden c loving(hilt be did not build of int- RES IND CON PB Omer
•" prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 20.00
❑ 1.as owner of the property,um exclusively contracting with ❑ ❑ 010 ❑
licensed contractors to construct the project ISea.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:'I'lie Contractor's License Law does not apply
w an owner el prupertywho builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects w.1h a,contractons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. , PARCEL NO.
❑ lam exempt under See. .B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Data WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK F;RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby uFm that 1 lease a ten ificate of conxnt to self-insure,
or a Certificate of Workers'Compensation Insurance.or a ceTut is
ZONING ENG.SITE NO.
copy thereof(Sec.3800,I-ab.C.).
Policy No, Cmnpiny -
O ❑ Canities copy is hereby furnished. FIRE SPRINK ENERGY T 24
'z 2 N Certified copy fllEd illLtle pry inspection division.
O A,plicaut�r-�_ j/s/f4 %• - n MISC.- REFER TO ORD. Y❑ N❑ Y N❑
CC CERTIFICATE OF IiXf MP1'I0N FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.L.
LU > COMPFNSATICN INSURANCE PLG.CONTR. LIC.NO. PLG.
C' o ('Phis section need not be contleted if the permit is Ion one TOTAL Y❑ N❑ Y❑ N❑
:D 2 hundred dullars(S 1001 or less.)
U O 1 certify that In the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued.I shall not employ any person in any manner so as to
U becume subject to the Workers'Compensation Laws of California.
ULU Date-Applicant ALTER OR ADD TO MECH. 4.00 BUILDING 3 ,50
} y NOTICE'TO AI'PLICAN'1': 11,after making this Certificate of Ex-
? eruption,you should become subject to the Workers'Compensation APPLIANCE - 4.00 PLAN CHECK
provisions of the Labor Code., you must forthwith comply with FEE ZS•o3
U such provisions or this permit shall be decmcd revoked. AIR HANDLING UNIT(TO lOJ1(1DC.F.M.) 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=CEM.) 5.00 SEISMIC FEE
'Y 1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) - 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lcnderi Name
Lender's NAddress UHEATI NG N IT(OVER 100,000 B.T.U.)7.50 ELECTRICI
1 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
ordinances and state laws relating to building construction, and BOILER-COW(3 H.P.or 100,000 B.T.U.) 4.00 e
hereby authorize representatives of this city to enter upon tum
above-mentioned property for inspection purposes. BOILER-COMP IOver 100,000BTU)SEE FEESCH. MECHA/Nf
ICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. I
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
PERMIT ISSUANCE 3.00
may in any ay accrue�kainst W Cit in consequence of the J
grnnlingo this rmu. // r MECH.CONT. LIC.NO. MECH.Igt� -$S
TOTAL
TOTAL
Signature of Applicant/Contractor Data I I I
INSPECTOR COPY