C6985 APPLICANT TO,FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
HERMI
amBUILDING PROJECT IDENTIFICATION T NUMBER
APPLICATION & PERMIT (/v/
auoG 6985
AOCRESS
-, - BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
%. OWNER'S r- PLAN CHECK VA (DATION
- N,Hv' '_ CITY. ELECTRIC PERMIT "FEE
+/ 'CONTRACTORS
- } NAME UTLETS-SWITCHES O
-RECEP 5.00/1.00 / -
L.C.NO. 'A LIGHTING FIXTURES 5.00/1.00
CONTRACTOR 415 APPLIANCES-RESIDENTIAL 4.00
AooRE s
PANELS 5.00 DATE OF APPLICATION
ARCIBr ECr SIGNS 6 OO PLAN CHECK FEE P.C.NO.
OR
NGINEER
' L.C.NO. SIGNS TRANS. 3.00
ADORESR ENG. SPECIALCIRCUIT 5,00 PERMIT VALIDATION
IP EMP.METER OR POLE INS. 15.00
A"PLICA
r ADDRESS MOTORS SEE FEE SCH. S �
141 1 ' Go SERVICE CHANGE 10.00
woo LICENSED CON'I'RACI'ORS UECLA NATION
a v I hereby atllnn Ihxe I am licensed under provisionsof Chapler 9 ISSUANCE DATE
m rt w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. I PLG. MECH.
F w z I"OfiS viuns Cnde,and my license is in full force and effect 1 ❑ EJ El' 0.A License Class_13l Lic.Number��
0 z °w )are 1_219-$_+_CnnlmClo,.C_- [2 A FJ....
a x EBUILDING PERMIT
¢ m w a OWNER-BUILDER DECLARATION INFORMATION
Aod MISC.- REFER TO ORD 1
w 3 ¢ n I hereby affirm that I am exempt from the Contractors License VALUATION T.
H LL 0 4 Law for the following reason.(Sec.7031.5.Business and Professions
Code; ISSUANCE 6.00 0 -
w � Code:Any city orcounly whichrequiresaperntil lacnnstma'alter,
¢ ¢ ¢ FO improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. /� O '
O E requires the applicant for such permit to file a signed statement that TOTAL D PERMIT TO
a w m w he is licensed pursuant to the provisions of the Contractor's License
F z a Law,(Chapter 9(commencing with Section 7000)of Division 3 of the
4 0 Business and Professions Code)or that he is exempt therefrom and QTY. - PLUMBING PERMIT FEE
¢ r m Ihu basis for the alleged exumplinn.Any violation of Section 7031.5 STOR TYPE ONSTR.
a 3 _ by any applic: v ufora pennif subjects the applicant ton civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not mare than five hundred dollars($500).): A
❑ rare
owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 occ.GROUP RES.UNITS
then 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 3
Codc:The Contractor's License Law does not apply to an owner of _
property who builds lir improves thereon,and who does such work FIXTURES-PER TRAP 4.00 36 SO.FT.FLOOR AREA TOTALACREAGE
himselfor through his own employees,provided that such improve-
clients are not intended orofferedforSale.If,however,the building GAS-EA.SYSTEM:I INC.4 OUTLETS 4.00
or improvement is sold within one year of completion, the owner-
buildcr will have lbe burden of proving(hat he did nor build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
prove(or purpose of sale.). R IND CON PB Onher r
❑ I,as owner of tie property,am exclusively contracting with INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑
li censed,comractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Profcssiaus Code: The Contractor's License Law dues nor apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 3-fl -.2 7--�
contracts for suds projects with a conlractods)licensed pursuant to /
the Cuntia,lori License Law. SEWER-SANITARY-STORM EA.200ft 0 TRACT No. PARCEL NO.
/8.0
❑ lam exempt under See ,B.&P.C.for this WATER HEATER W/VENT 4.00 -'
realonIt
Owner Date WAfER SYSTEM 4.00 - ACC.DATE ACC.FILE NO.
WORKERS'COMPENSA'FION DECLARATION WATER TREATING EQUIP. -4.00
1 hereby affirm Ilial I have a cenificale ofconseat le self-insure. ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
cupy Ihereol'(See 3X00.Lab.C.) Il-RCS
Policy No. Company "RO J At l p 2 e.4 ]
O - Certified Copy is hereby fumishe . FIRE SPRINK ENERGY T 24
Z Z c4lrlitied Copy is fi wi I the city inspection ivision' MISC.- REFER TO ORD.
O Applicadf - Y ❑ N❑ Y ❑ N❑
CCTPERMIT ISSUANCE 6.006 FLOOOZONE A.L.uc.
CISR'1'1 PIG\'I'Ii OP EX1i MVI IDN FROM WORKIiRS'
LU D CO.% _'NSAT'ION INSURANCE PLG.CONTR. n LIC.NO. PLG. �LC
d O (This section need not be Completed if the permit is for one TOTAL // Y❑ N❑ Y ❑ -N❑
DZ hundred dollars(S 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 N mit is issued,I.shall not employ any person in any manner m as to / q
OW m heconsubject to the Workers'Canipersal ion Laws of California. BUILDING rA 0( J'Ql�
O_ nam APph°ant ALTER OR ADD TO MECH. 4.00
} m NOTICE TO APPLICANT': If,atter making this Certificate of lis
F Z ernplion,You should het'mrC subject m the Workers'Con pensation 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,CODGF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IOAOOC.F.M.) 5.00 SEISMIC FEE /a
I hereby anion flat there is u construction lending agency for EXHAUST HOOD(WITH DUCT) 2:00 est,
the performance of the work for which this permit is issued(Sec. 'MICROFILM
3097,Ow C.). J I HEATING UNIT(TO 100,000 B.T.U.) 4.00
LCndCr's Acidic HEATING QNIT(OV ER 100,000 B.T-.U.P.50 /U Si
Lcndcr's Address ELECTRIC 3
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 - 6w
infornation is correct. 1 agree to comply with all city and comply PLUMBING G
�..� ordinances and state laws relating to building construdfmu and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorise representatives of this city m em
upon the ?
abovemenlioned properly for inspection purposes. BOILER-COMP(Over 100,000 BTU(SEE FEE SCH. MECHANICAL / G
(We) agree to save. indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, coats amd expenses which PERMIT ISSUANCE 3.001,3 - CONST.TAX zarL r,
may in any way accrue against said City in consequence of the
g,antingoflhispel-nlL MECH.CONT. LI .NO. MECH.
..per TOTAL & w TOTAL // 3a
fSfiltulturc I' /Contractor ale VF ' 1 /
INSPECT(J]1COPY