6968 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
aonREss oS 4C' -q -tS JP. BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 6968-
CANNER S
PLAN CHECK VALIDATION
""Ne DTV. ELECTRIC PERMIT FEE
• /-/IA)A) PHONE��//-9�1�a
CONTRACTORS OUTLETS-SWITCHES
N -RECEP 5.00/1.00
AME
Ai "] IA) uC NO yy j LIGHTING FIXTURES 5.00/1.00
CONTRACTORS Osc' �� JOAPPLIANCES-RESIDENTIAL 4.00
IIP� //��//.�
PNONF�979"O/-/ PANELS 5.00 DATE OF APPLICATION
ARCHITECTSIGNS 6,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.NO, SIGNS TRANS. 3.00
ARCH,OR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION "
ADDRESS
. ZIP EMP. METER OR POLE INS. .15.00
ADDRESS
D
pR
AMOTORS SEE FEE SCH.
DRESEssS
SERVICE CHANGE 10.00
o o I,ICI?NSl,D CON'I'RACIORS DECLARATION
< U U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
,n 2 w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H w i Professions Code. nd m license is in full force:)t d effect ❑ ❑ ❑
z oz m - License Class - Lic.Numbe A
oH o Date Contractor
< y E BUILDING PERMIT
w 4 OWNER-BUILDER UBCLARA'r ON INFORMATION
od °
w 3 u 1 hereby vlfinot that I am exempt Gom'the Cont raclo! MISC.- REFER TO ORD
s License VALUATION $/FT.
F u o j Law for the billowing reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,alter,
CE ¢ ¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
to
w m u requires the applicant for such permit to file a signed statement that TOTAL P IT T
he is licensed pursuant to the provisions of the Contractor's License
r z i
Law(Chapter 9(commencing with Section 7000)of Division 3 mfthe N
4 Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ Fo the basis for the alloyed exemption.Any violation ofSection7031,5 STORIES TVE7CONSTR.
ate - by any applicant lira permit subjects the applicant to a civil penalty ALTER-D AIN&VENT-WATER IEA.14.00
of not more than five hundred dollars(8500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 occ.GROUP RES.UNITS
their sole com pensalion,will do the work,and the structure is not
intended or offered for in (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
properly who builds m improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SD.FT.FLOOR AREA TOTAL ACREAGE
• hits mself or through his own employces,provided that such improve
meaare not intended or offered for sale If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
r 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 d proving that he did not build or int ES IND CON PB Omer
prove for purpose of sale.) INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct Dte project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 SSESSORS PARCEL NO.
and Professions Code:The Contractor's License Lew does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such pmjeCh with a CUnt(aCIOr(a)licensed Pursuant to
the Commolnr's License L.,.. SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO. PARCEL NO.
O lam exempt under Sea ,It.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKIiRs'COMPFNSA1ION DECLARATION WATER TREATING EQUIP. 4.00
1 hetehy,firm that 1 h'avc a carlil'icale of consent m scifov a e. ZONING ENG.SITE NO.
e
urlil'icata of Workcrx'Colnpen.mtion Inwrmme,or u certified
copy Tarot(Sec.3800,LIb f:.).
Policy No 1,J444-QCompany OEAjrEe.<,qr
O ❑ reit lfied ISI by'In, shed, FIRE SPRINK ENERGY T24
Z Z cerlifiet o - fled I I{ �'y it+pccfm, division. MISC.-' REFER TO ORD. y N y N
O Applicant V ❑ ❑ ❑ ❑
Cr T CER'1'IFICA'[It 0171 Xli M111[ON FROM WORKERS. PERMIT ISSUANCE 6.00 FI.00DZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. ❑C.NO. PLG.
O (This celion need not be completed if the penoil is for one TOTAL Y❑ N❑ Y ❑ N❑
Z hundred dollar,($100)or less.)
L) O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mil is issued,I shall not employ any person in any manner to as to
Q become subject to the Workers'Compensation Laws of California.
ED Dat. ApphCantALTER OR ADD TO MECH. 4.00 BUILDING
} rn NOTICI7 TO APPLICANT: If,after making this.Certificate of Ex.
♦- Z antinion,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 be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIRHANOLING UNIT(OVER 100ODCEM.) 5.00 SEISMIC FEE
i I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
.the perlirmunce of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00 AA
Lcndch Nanta
Lender's Address HEATI NG UN IT(OV ER 100,000 B.T.U.)7.50 ELECTRIC
I ccrtily that I have read this application and scot,that the above VENTILATION FAN (SINGLE) 3.00
. information is C...ect. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP I3 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-mentione&property for inspection purposes.
(We) agree to save, indemnify and keep honnlcss the Cily of MISC.- REFER TO ORD.
Cupertino against liabilities,judgnrnuts, Costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
i
may i y way occruc against said City in consequence of the
grant go Ih' pernil. ME H.CONT. LIG NO. MECH.
Signature u Applicant Contra or Uale
ff r/� /> ITiuG �y6 V TOTAL' Oct TOTAL
INSPECTOR COPY