6939 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMITNUMBER
BUILDING APPLICATION & PERMIT 6939
ADDRESS I ^_I^ �Ov
W `v( . BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
R'S
OWNEPLAN CHECK VALIDATION
E• 99 .8393 QTY. ELECTRIC PERMIT FEE orvE
croR'$
NAME UTLETS-SWITCHES-RECEP 5.00/1.00
NAME
I- pJnJ=LIC.NO. LIGHTING FIXTURES 5.00/1.00
r,D nncloHs v�0 I�I-1�
TJ s APPLIANCES-RESIDENTIAL 4.00
Hess v
PHONE PANELS 5.00 DATE OF APPLICATION
OR rt CT SIGNS 6.00 PLAN CHECK FEE D.C.NO
ENGINEER
LIC.No. SIGNS TRANS. 3.00
AARDDRESS ENc, SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00 C
ADDRESS, MOTORS SEE FEE SCH. / J
ADDRESS- 7Uy-'
SERVICE CHANGE 10.00 pp
a LICENSED CONTRACTORS D[CIARATION d yS rf
O
a o I herebyun,rei affirm thatI am licensed under provisions n(Chapter 9 ISSUANCE DATE
m Q wI t num n'ing with S ee'lion 7000)of U v Sion 3 of the Busrncss and BLDG, ELECT. PLC. MECH.
z B - Cod lid wnsc I,I"I'Ll!fur'•. of r
zow Ile nu. -s Lie Numb r" r•. ..� - �. - ❑r. ..�.:. ..R-.
0 w Dem Contra mr - 1
a x E -a BUILDING PERMIT
¢ ¢ w c OWNER-BUILDER DECLARATIOM1
o a U MISC.- REFER TO ORD INFORMATION
X 3 LL N I hereby atfir r that 1 am exempt from the Contractor's License
u o v, Law lilt the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE VALUAnoN S/FT.
� - � Code:Any city mcounty which requires a permit to construct,alR•q 6.00
Qrt 4 improve,demolish,or rCpam any structure,prior ID its issuance,also ELEC.CONTR. LIG NO. ELEC.
0¢ requires(he applicant for such permit 10 file a signed statement that TOTAL PERMIT TO
A w m" he is licensed pursuant to the provisions of the Contractor's License
H i
z Law(Chapter 9(commencing with Section 70001of Division 3 oftle MSC.
- Q Btusiares and Professions Code)or that the is exempt therefrom and QTY. PLUMBING PERMIT FEE
re r p I is basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
in aim by any applicant fora permit subjectsthe applicant toacivilpenalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars($500t):
❑ I,as owner of the property,or my col ployces will,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'PIED Contractors License Law does not apply to an owner of
property who builds or Improves thercon,and who does such work FIXTURES-PER TRAP 4.00 50.FT,FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve
-
mentsarenotintendedoroffered for sale.ll',however,the building GAS-EA.SYSTEM-l1NC.40UTLETS 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 proving that he did not build m im-
provel'orpurposeofsale.). INDUSTRIAL WASTE INTER. 2000 RES IND CON PB other
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed Contractors t0 construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.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 lot such projects with a contractons)licensed pursuant to
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ l on exempt under Ser.-,BAP.C.for this WATER HEATER W/VENT 4.00
OW,:cl
3
Uwnur Uwo WATER SYSTEM 4.00 ACCC.DATE ACC.FILE NO.
WORK ERS'COMPENSAI'ION DIiCI.ARA'I'ION WATER TREATING EQUIP. 4.00 •S
I hereby affrm that I have a certificate of consent tosell-insuR,
r a certificate of Workers'Compensation Insurance ora certified ',,ZONING ._ENG.SITE NO.
copy the f
Icl¢YN 4� - -7-
❑ L li(i d Dp) 's'her eby'fur Or t . 1 'r( - l - .-aY - - FIRE SPR INK ENERGYT24
C rt l {�yry rsf deJ w th t e city msp coon divisi 'k
z0 Applicant .}SL°� 4}� 11�L b MISC.- REFER TO ORD. v ❑ NO v ❑ NO
CC CERTIFICATE OF FAFNIPTION PROM WORKERS' PERMIT ISSUANCE 6.00 -FLOOD ZONE A.C.UC.
LIJ > COlIPFNSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
= CI'his section need not be completed if the permit is for one TOTAL Y❑ No Y❑ No
Z
hundred dollars(51001 or less]
U O 1 certify tial in the performance of Doe work for whieh(his per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mil is issued, 1 shall not employ any pertain in any manner m as to
U became subject to the Workers
} Compensation Laws of California.
> A Late Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
w
NO '1'O APPIJCANr. If, making this Certificate of Ex- .
Z_ CrllpHoll,you should become subject to the Workco C-ompcnsatioa APPLIANCE 4.00 PLAN CHECK
pruvisians of the Labor Code, you most forthwith comply with FEE
U such previsions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) -,200
the peffornance of the work for which this permit is issued(Sec. MICROFILM
3097,Ci,,C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
• information is correct, 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-ODMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorise representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL 7l'
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 CONST.TAX
may in any way accrue against said City in con,eque n cc of the
gr lg of this permit MECH.CONT. LIC.No. MECH. r
3 �11� TOTALTOTAL
'i re ol'Applicanf/Contract r ( ate IrvO
INSPECTOR COPY