5662 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
t 'BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRE55 'D �ltisDzt' BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
_ _ 5662
OwNE 'S ?il/ J - PLAN CHECK VALIDATION
NAME LL//VV//// / OTY., ELECTRIC PERMIT , 'FEE
S Fp/z,Le NW PHONE _ O O
CONTRACTORS
NOUTLETS-SWITCHES-RECEP 5.00/1.00
AM
ala Pahl& LIC NO /�V ( V LIGHTING FIXTURES 5.00/1.00
CONTRAS ORS i ��� PPLIANCES-RESIDENTIAL 4.00
t /J)
�U � /G/r�•5' RHONE •Q PANELS 5.00 DATE OF APPLICATION
ARCHITECTSIGNS 6,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER '
LIC.NO. SIGNS TRANS 3.00
ARC R.RESS
OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 15.X)
ADDRESS MOTORS SEE FEE SCH. J
ADDRESS
SERVICE CHANGE - 10.00
wo o LICENSED CON I'RACfORS DECLARATION
¢ mo u I hereby affirm that I am licensed under provisions of Chapter 9 1 Vx ISSUANCE DATE
(commencing with Section 7000)of Division 3 of(be Business anJ BLDC. ELECT., PLG. MECH.
F - I'rafessions C. y license is in full force i d f'e t. ❑ ❑ ❑
z o w - License Clas9 ((.. Lic.Number
g r . )ate � Contractor y4• ln��
BUILDING PERMIT
¢ ¢ w ¢r OWNER-BUILDER DECLARATION
o INFORMATION
aoA MISC. REFER TO ORD
w g u_ `m 1 hereby al firm LOU I am exempt from the Contractors License VALUATION
u0¢ Law for the following reason. 7031.5,Businessand Professions PERMIT ISSUANCE S/FT.
_ s.Bo 4f,3
Code:Any city or county which requires a permit m umstruct,alter, Q
¢ Q p improve,demolish,or repair any structure,poor to its issuance,also ELEC.CONTR. LIG N0. ELEC.
- O¢ requires the applicant for such permit Io file a signed statement that TOTAL PERMIT TO
n w m he is licensed pursuant to the provisions of the Contractor's License
F a ¢
Law(Chapter 9(commencingwi(h Section 7000)of Division 3 of the R.2
re4 i D Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT /Y
re H o the basis for the alleged exemption.Any violation of Section 7031.5 vv vv` J. ISTC10" TYPE CONSTR.
to
by any applicant for a permit subjects the applicant to a Civil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00 .
of not marc(Iran Ove hundred dollars($500)): ��.
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 RES.UNITS
their sole compensation,will do the..,it,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND...4.00
Code:'1'Iie Contractor's License Law does not apply to an owner of -
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
ments are not intended or offcrect for sale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
r improvement is sold within one year of completion. Lire owner- GAS-EASYSTEM-OVER 4 IEA) 100 BUILDING USE
builder will have the burden of proving that h . . .
e did not build or iso- RES IND CON PB Omer
prove torp......of sale). INDUSTR IALWASTE INTER.' '20.00 ❑ ❑ EJ 11 El
I,as owner of tham e property, exclusively contracting with
licensed contractors to construct the project(Sea 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 tticovon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with is contractors)licensed pursuant to
the Contractors License Law. • SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ luso exenmt under Sec. ,B.&BC.Ibr this WATER HEATER W/VENT 4.00
Own, Dale WATER SYSTEM 4.00 - ACC.DATE ACC.FILE NO.
WORK ERS'COMPCNSA'I'ION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby al lirm Ihet I have a certificate of consent to sell-insiire. •' ZONING ENG.SITE NO.
or a certificate of Workers Compensation Insurance, certified r
copy thmeo��tt�Sf c�.38 0;LohC.I r
Policy N'o.7 � CO.Pany-e)� w �c
❑ Evel
": Py rs herchy furnished. FIRE BPRINK ENERGY T 24
z-R erril'icd ,O+y LisOui Jvd�d city inspcc(ion division. MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
O App nIY go
Fy PERMIT ISSUANCE 6.00 FLOOOZONE AL.0 C.
LU CE RT'IPICAT PENSAEMI'I'ION NS FROM WOR KIiRS'
W �_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL. O (This section need not becora pitted'if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
:) Z hundred dollars IS 100)or les-) -
U O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
W P mit is issued,I shall not employ any person in any manner so as to
U bCQo111CSLzbjecttp(he Workers'Compmrsa(inn Lawsof Calilirrnia.
O w Date Applicant BUILDING'-
IL ALTER OR ADD TO MECH. 4.00 d V
} h NOTICE TO APPLICANI': If,after making this Certificate of fix- `
F Z tmption,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 ITO 10,000CF.11i 3.00
CONST R.11c❑ON LENDING AGENCY AIR HANDLING UNIT(OVER I0,000C.F.M.) 5.00 J SEISMIC'FEE
I 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
Lender',Name
Lender's NamAddress - HEATI NG UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
_
1 certify than have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
,� - information is correct i agree to comply with all city and county' BOILER-COMP(3 H.P.or 100,000 B.T.U) 4.00 PLUMBING
ordinances and state laws relating m building construction, and
1 hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTUI'SEE FEESCH, MECHANICAL
above-mmuioned Property for inspection purposes.
(We) agree (O save, indemnify and keep harmless the City of MISC.- 'REFER TO ORD'. '
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX -
may in any way accrue against.said City in consequence of the PERMIT ISSUANCE 3.00
gmntingoftl permit. MECH.CONT. LIC.NO. MECH. '-
TOTAL
�A,W �6�/f'� TOTAL
Signature of Applicant/Contractor ate
OFFICE COPY _. ,-