5740 APPLICANT T,O FILL'IN INFORMATION WITHIN RED,.LINES - USE BALL POINT PEN ONLY
1, '- - - , - PERMIT NUMBER
BUILDIBUILDING PROJECTlDENTIFICATION APPLICATION & PERMIT
AODRENG (''L1 5740
ADONESS I I -
- :L r• BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S .- PLAN CHECK VALIDATION
NAME .f./tT.
A b - OTY. ELECTRIC PERMIT - FEE
PXpNE'
CONTRACTORS OUTLETS-SWITCHES-RECEP 5.00/1.00
N NT
I- LIC.NO. LIGHTING FIXTURES 5.00/1.00
CONTRACTORS ' APPLIANCES-RESIDENTIAL 4.00
ApoREss 4- 5
22166 M(rWr l3� ONF b PANELS 5.04 DATE OF APPLICATION
ARCHITECT - SIGN$ 6,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER. ' '
' sec.NO. - SIGNS TRANS,. ' 3.00
AARCH.OR ODR ESS,ENG.' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 15.00
uT's
APPcANMOTORS SEE FEE SCH.
ADDRESS
�-rZZI 'J(r11t1/nP,r yl✓(.(,- SERVICE CHANGE 10.00 /L
F o O LICENSED'CONTRACTORS DECLARATION - - -
wIhereby aflirm.thull um-ticensed.under provisionso'Chapter9 w ISSUANCE DATE
v, (commencing with 5 lion 7000)of DO stun 3 of lou Business and -
< w O !'n,M - BLDG. ELECT. 'PLG. MECH.
H m z Professions Cod a ny I¢enu 1 m full force,a-n feel x—V vlL
z o vi - Lhccn Class Lu \umbo Ho ��a ❑ ❑ 1:1
❑
O 0 Date C nlmcfor FFII//mmii n_
BUILDING PERMIT
¢ ¢w¢
OWNER-BUILDER DECLARATION _
o A pMISC.— .REFER TO ORD INFORMATION
w3 LL H Ihereby affirm that I am exempt from tire Contractor's License _ VALUATION S/FT.
FLLtm`4 Law fur the following reason.(Sec.7031.5,Businesvand Professions P ISSUANCE
Code':Any city or county which rcyuiresapermif lO construct;alter, 00
Q Q Q 0 improve,demolish,or repot!any$QIICInR,p110!to its RSndneQ aI50 ELEG CONTR. ELEC.
DLL requires the applicant for such permit to file a signed statement that TOTAL .. PERMIT TO
n w m he is licensed pursuant to the prrtrvi,i ons ofit,Contractor's License - nn
Fza Law(Chapter9(commencing with Section 7000)of Division 3 ofthe Ke�'('1(Lr,
Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE II ''
¢moo thebuskfor the alleged exemption.Any violation ofSection 7031.5STORIES TYPE CONSTR.
d';m by any applicant for a permit subjects the applicant o a ciW'penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more lour.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 compensation,will do the work,and the structure Is not
.intended or offered Ior sale(Sec. 7044,-Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
.properly who builds or improves thereon,and who docs such"work FIXTURES-PER TRAP - - 4.00 56 IT.FLOOR AREA TOTAL ACREAGE
'• himself or through his own employees,'provided that such improve-
Dentsare-not intended or offered forsale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or im- R S IND CON PB Omer,
prove for purpose of Sale.). INDUSTRIAL WASTE INTER2000
'❑ I,as owner of lire properly,am exclusively commctin'g with . .
❑ ❑ ❑ -❑
it"nsed contractors lu construct the project(Set.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and I'rofessiom 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 for such projects wilha contmdot sl licensed pursuant to SEWER-SANITARY--STORM EA:200ft/8.00 TRACT NO. PARCEL NO.
thetracts for such
ct License is Lu. '
❑ lam exempt undeegoc. .fl.&P.C:I'or this WATER HEATER W/VENT 4.00
asset -
Owner" Uate - - . WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm 1ve a artifcatt pf consent to self-insure, - ZONING of a eerlifiCme of s Conymnsut inn Insurance;nr a certified ENG.SITE NO.
copy flier f( c� IB .Lab.C.l.Q� ^1 � rye O ,.,�(�
ofcy No. Company G/IULU ++IDI/I WIIF�
O'' 'Certified copy is hereby furnish` ' FIRE BPRINK ENERGY T-Z4
Z Z Certll cl T Y'•is fled.wish the city inspection division -
O Applicant f"10 nTlz. tet' aY10 A MISC:- REFER TO ORD. Y ❑ IN Y ❑ N❑ s
M = CERT'IPICATE OP EXEMPTION FROM WORKERS' .PERMIT ISSUANCE 6.00 FLOOOZONE A.L.U.C.
LU >_ 20M111iNSAIION.INSURANCF PLG.CONTR. ' ❑C.No. PLG,
L O (This ''echo" need'not be completed if the permit is for one '' TOTAL v❑• N❑ Y 11N❑
� Z hundred du llars IS 100)or less) ..
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I— mit is issued,I shall not employ Dry person in any manner so as to
OU become subject to the Workers'Compensation Laws of California. r�
0. Dam Applicant ALTER OR ADD TO MECH. 4.00 BUILDING QV sa
} rn NOTICE TO APPLICAN"C If,after making this Certificate of
H Z elilption,you should become subject to the Workerr'Colnpersultoo APPLIANCE 4.00 PLAN CHECK'F
provisions of the Labor Code, you must forthwith comply with EE^'""""^
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.). 3.00
CONST'RucrIONLENDINGAGENCY AIR HANDLING UNIT(OVER 10=C.F.M.)'5.00 SEISMIC FEE 170
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) . 2.00
the performance of the work for which this permit is issued(Sec.- MICROFILM
3097,Civ C.). - - HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lenrim's Name HEATING UNIT IOVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
Icertity that l have read lhiSupplcntion and state that the ubovQ VENTILATION FAN (SINGLE) 3.00 '
information is correct.I agree to comply with all city and county PLUMBING
ordinances unit 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 INDWO 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 CX
purses which CONST.TAX
may in any way accrue against said City in Consequence of the PERMIT ISSUANCE 3.00
gran( g of this peen -I� MECH.CONT. LIC.NO. MECH. C"-"_ ✓1 TOTAL TOTAL 8�
.f
Signature of Appliciniglantractur U [e
., OFFICE COPY