C6107 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENTI FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT . r
ADDRESS loss% T� \ W\Y�,.r A1 07
1VKw^C.\ BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S ECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE
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V �I, ; {�..\���` PHONE ass-at01
NAME crony OUTLETS-SWITCHES-RECEP .5.00/1.00
'�NA-�ME� pC <
IWC7tI VN sees NC L( ITl lot LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'$
V�CJt
-RESIDENTIAL 4.00Cx `setC\ APPLIANCES
tONE96-1-a0`4y PANELS
5.00 DATE OF APPLICATION
ARCRITECTSIGNS 6.00
PLAN CNECK FEE P.C.NO.
OR
ENGINEER
LIC,No. SIGNS TRANS. 3.00
ARCH,
ENG. PERMIT
CIRCUIT 5.0Q PERMIT VALIDATION
2,P EMP. METER OR POLE INS. 15A0i
APPLICANT MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
L i
w O o LICENSIi1)CONTRACTORS DECLARATION �CE D L.
a U u I hereby affirm (hut I am licensed under provisions of Chapter 9 ISSUANCE GATE
H rt w
Leon unemem,with Section 7000)of Division 3 of(Ire Business anti BLDG. ELECT. PLG? MECH.
r y z Professions Codeer m license is in full force and effect.
License I�y„-.�j .-I.ic.Number 1Iq ❑ ❑ ❑ ❑
0 z r CUa(C Contrndor
a y eRJICyS BUILDING PERMIT
¢ ¢ w < OWNER-BUILUER DI:CLARA'PION INFORMATION
w ;LL r MISC. REFER TO ORD
I hcrchy affirm that I am exempt from tit,Contractor's Ciccone
-
F LLOQ Law I or the following reason.(Sec.7031.5,Business and Professions pERMIT ISSUANCE 6.00 d VALUATION $/FT.
Code:A ny city or county which requires a permit to construct.alter, le
Qa Q Q improve,demolish,or repair any structure,prior to its issuance.also ELEC.CONTR_ LIC.NO. ELEG S I��1 O
O ¢ retluires the applicant for such permit io Glc A signed statement that TOTAL PERMIT TO
wm u- he is licensed pursuant to the provisions of the Contractor's License
H z i Law(Chapter 9(commencing with Section 7000)of Division 3 of Pe R� lZoo�-;.
- 4 Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ H is the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
e- ;m by any applicant for a pemli(subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
01not more than fivehuni red dollars($500)J:
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 DCC.GROUP RES.UNITS
Their sole compensation,will do tire work,and (he struC(ura is not
irl coded or offered for sale (Sec. 7044, business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:'I'hc Contractor's License Law dues not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 So-FTFLOOH AREA TOTAL ACREAGE
hip,sell or through his own employees,provided that such hiprove�
a•y
WIGS are notfntended or offered for sale.If,howev'e'rihcbuildidg +GAS-EA.SYSTEM-I INCi'40UTL'ET$'-4.00
or improve,co;t is sold within ane year of completion,the owner- -
builder will have the burden of proving(hat he did not build or On. GAS EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING uSERE ` IND CON PB Diner
INDUSTRIAL 20.00
prove for purpose of sale.) STRIAL WASTE INTER-1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ I. ❑
licensed contractors to construct (he project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B:x 5.00 ASSESSORS PARCEL NOS
and Professions Code:'1'lie Contractor's License Law does not ripply
to an owner of property who builds or improves(hereon,and who LAWN SPRINKLERS-OVER 5(EA.)' 1.00
-� cmtlmel,for such project,with u<ontracto,(,)licensed pursuant To
I ht.Cml traanr's Livens,Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
(l I am exempt under Sec. ,B.&PC.Iia Pis WATER HEATER W/VENT 4.00
/ reason
F Owner Da(c WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMITENSATION DECLARATION WATER TREATING EQUIP. 4-00
I hereby affirm that I have a certificate of consent or selfinxure, ZONING ENG.SITE NO.
1),a certificate of Workers'Compensation Insur or a cert ifird
[aur Meregqf�seQ9e�,3�81 0� ah�,C�.22. �•J�5 X4'1
Policy ere&
CI CerlificJ Copy is hereby furnished 1 k FIRE SPRINK ENERGY T24
Z 2 yA Cert fie 'op s tiled with the city inspection division. REFER TO ORD
O Applicam MIS,.- . Y ❑ N❑ v ❑ No
CC Ln CERI'IFACA II i A EXEMPI'I)N PROM WORKERS' PERMIT ISSUANCE . 6.00 FLOOD ZONE A.L.0 C.
W > COMPI-NSA'I'ION INSURANCE. PLG.CONTR. LIC.NO. PLG.
CL 0 (this section need not be completed if the permit is for one TOTAL V❑ N❑ Y E] NE]
hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
W H mit is issued,1 shall not employ any person in any mannerso as to
U become subject(o the Workers Compensation Laws o(Calilornia.
U aDate Applicant ALTER OR ADD TO MECH. 4.00 BUILDING �50
} N NOPCE*10 APPLICANT: If,after making this Certificate of lix-
F ? enlption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall he devoted revoked. AIR HANDLING UNIT(TO 10WOCF.M.) 3.00
CONSTRIICI'ION LENDING AGENCY AIR HANDLING UNIT(OVER 1Q0WC.EM.) 5.00 SEISMIC FEE ,'SQ
1 hereby ulluot that (here is a conelruclion lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the pedorniance of the work To which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT I0 VER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that 1 nave read fids 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-COMP(3 H.P.or 100,000 B.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) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 j CONST.TAX
may -n any way accrue against said City in consequence .1 tiro
gra ti gof s'pernt it. MECH.CONT. LIG NO. MECH.
(LJ -AL-LsS roTAL TOTAL 'S l .00
SiW,atu of Ap icant/Cont ctor Date
INSPECTOR COPY