6961 +► APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
nooness BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 6961
D -BA
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O NER'S -B" ,. 1 �� PLAN CHECK VALIDATION
NAME M QTY• ELECTRIC PERMIT FEE
• PNONE
ODNTITACTOAS Q�u�r
NAME UTLETS-SWITCHES-RECEP 5.00/1.00 VV /
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LIGHTING FIXTURES 5.00/1.00 S . /f ..e3 �
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CONTRACTOR RE /O'S / PPLIANCES-RESIDENTIAL 4.00
CONDDV
PEH)NII, 3521 PANELS 5.00 DATE OF APPLICATION
'ARCHITECT/�� G �/ - �/'� SIGNS B PLAN CHECK FEE P.C.NO.
ENGINEER
LIC..xo. SIGNS TRANS. 3.00
ARCH.OR
' \ FG� '�'� nhr uf $ 10 SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
-
/'" S z,P EMP.METER OR POLE INS. 15.00 n /
APPLICANT MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00 �Gq p
wO o hICIiN $IiU CON'I'RACI'URS DECLARATION �-7 //0 S 1
is u 1 herehy affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
v~i z H (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F n- professions Code, m license e'in full for a¢d Tffycl.
z o m Licenu Class Lia Number4.3.7_�/a
0z w Gale_ Contractor
ycs�
¢ Y f BUILDING PERMIT
¢ Q w a OWNIi R-ft UILDIiR DI?CLARA'fION INFORMATION
K
3 1 hereby affirm for I am exempt from the Contractor's License
MISC.- REFER TO ORD
a G
uLaw for[lie Hollowing rea (Se703S,tlusinessand professions VALUATION $/FT.
F o¢ PERMIT ISSUANCE
6.00
Code:Any city or county which requires permit to construct,aIle, tX� u V b
¢ rz ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. /
- O u requires the applicant for such permit to file a signet)statement that TOTAL PERMIT TO
wes
he is licensed pursuant to the provisions of the Contractor's License
Uzi
Law(Chalier9(commencing with Section 7000)of Division
3ofthe j'�a✓4 / PRU✓C,
¢ Businus:rad Professions Code) it that he is exennpt therefrom and QTY. PLUMBING PERMIT FEE tl
¢ = $ the basis for the alleged exenmtion.Any violation of Section 7031.5 (� STORIES TYPE CONSTR.
A , by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00 4
of not more than five hundred dollars(S500k):
❑ I,as owner of the mopery,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 (Scc. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code:"file Contractor's Licee,Law docs not apply In an owner of
property who builds or innproves:thercon,and who does such work FIXTURES-PER TRAP 4.00 So.FT.FLOOR AREA TOTAL-ACREAGE
himself or through his own ernployees,provided that such on prove.
. . ments are not intended or offered for sale.If.however,the building ' GAS-EA.SYSTEM-11NC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 IEA.) - 1:00 BUILDING USE
builder will have the burden of proving that he did not build or int - . RES IND CON PB Oma,
prove for purpose of sale.). 1 N DUSTR I A L WASTE INTER. 20.00
❑ I,as owner of the property,um exclusively cool reeling with ❑ ❑ ❑ ❑ ❑
licensed contractors w.cunxtruef the project(Sec.7044,Business LAWN SPRINKLERS-1INC 5V.B. , 5.00 ASSESSORS PARCEL NO.
and Professions Code:The 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 lotctor*s h censeprojectsL with a comraclorfs)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the Cmdmet such
License Law.
❑ tum exempt under Sec. ,B.8-P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACG FILE No.
WORKI'RS'COMPI?NSA'I'ION 011CLABA'I'ION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified r
copyllort.f(Scc-3800,LabC.
Policy'No, Company ��lJGIfLP f c'
kwip
O ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T"24
Z z yW Cerlified copy is fled with the city inspection division. MISC.- REFER TO ORD.
07Appli,l... r J Y ❑ . N❑ Y ❑ N❑
N CIi B'1'IPICATI 017 Ex EMPf1ON PROM WORKERS' PERMIT ISSUANCE' 6.00 FLOOD ZONE A1.O.C.
LU � CONIPCNSATION
INSURANCE PLG.CONTR. LIC.N0. PLG'
d O y EJ N❑ Y❑ NC]
(Phis action need not be completed if Bra permit is for one TOTAL
::) z hundred dollaO(S100)ar less.)
U O 1 certify that in tie performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- -unit is issued, 1 shall not employ any person in:my mannersis as to
U lie wlne subject to the Worker.,'Cmnn P, satmi,Laws of California.
LU Dato A� licanl BUILDING 'O
el- In ALTER OR ADD TO MECH. 4.00 I i
} W NO110E "1'0 APPLICANT': If,after making this Certificate of I:,-
F ? emption.you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
U prof siovnumshe this
Code, you must forthwith comply with FEE
provisions permit shun be deemed revoked. AIR HANDLING UNIT(TO I0=C.F.M.) 3.00
CONSTRUC'T'ION LENDINGAGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE / t2
I hereby Minn that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this pen..it is issued(See. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Address Lender's AddrHEATING UNIT(OVER 100,000 B.T.U.)7.50
ELECTRIC
1 certify mm I have read this application end state that the above VENTILATION FANr(SINGLE) 3.00
information is correct, I agree to comply with all city anJ county gQILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and stale laws relating to building construction, and
hereby mrtharize representatives .1 this city to enter upon the BOILER-COMP (Ove,100,000 BTU)SEE FEE SCH. MECHANICAL'
ubovomenlianed property for inspection purposes.
(We) agree to save, indemnify and keep haalless the City of MISC.- REFER TO ORD.
Cupertino agar liabilities,judgments, costs and expenses which CONST.TAX
may gin any "erre ag 'oat mid ity in conk It a of the PERMIT ISSUANCE 3.00
granting of f mit, MECH.CONT. LIC.NO. MECH,
4 1g TOTAL TOTAL 117,11
Signat A p ice Co uc r Darfic
INSPECTOR COPY