6969 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION - I PERMIT NUMBER
BUILDING APPLICATION &'PERMIT
ADDRESS D W901204 BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 6969
OWNER'
PLAN CHECK VALIDATION
OTY. . ELECTRIC PERMIT - FEE
• PRONE
AME"cT Rs UTLETS-SWITCHES-RECEP 5.00/1.00
el� /1/ LIa No. �4YyM LIGHTING FIXTURES 5.00/1.00 -
CONTRACTOR S1-51 APPLIANCES-RESIDENTIAL - 4.00
aooREss �7rll r5F .
O BONE PANELS 5.00 DATE OF APPLICATION
ARC ITEci SIGNS 6.00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER
- uc.NO. SIGNS TRANS.' 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS SPECIALCIRCUIT 5.00
ZIP EMP.METER OR POLE INS. 15.00 -
APPLICANT sS MOTORS SEE FEE SCH. l'
SERVICE CHANGE 10.00 7{�"
woo LICENSED CONTRACTORS DECLARATION
¢ I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
E. a re (commencing with Section 7000)of Division 3 of the Business and - BLDG. ELECT. PLG. MECH.
F w z Professions Code. ucar
se I se is in full force a _
z O m- License'Chpss-p�L,�gp}{�y,�LLic.Number - A p)
Q z r w COmree(nr '
< y s I BUILDING PERMIT
¢ ¢w¢ OWNER-BUILDER DECLARATION --
MISC.- REFERITUORD 1Jjdj INFORMATION
w LL r I hereby affirm that I am exempt from the Contmdor's License vaLUATION
.. O a Law for the following reason.(Sec.7031.5,Businessand Peolesslors PERMIT,ISSUANCE S/FT.
Code:Any city or county which requires a permit to construct,alter, ns 6.00 -- -
arQQQ improve, or repair any structure,priorto its issuance,also ELEC.CONTR. LIC.NO. ' ELECT L`UloT[�
O LL requires the applicant for such permit to file a signed statement that TOTAL //`' PERMIT T//P/�
a w R be is licensed pursuam m the provisions of the Contrmlor's License M�
Law(Chapter 9(cormnencing with Section 7000).f Division 3 ofthe -
¢ Business and Professions Code)or that he is exempt therefrom and [,GAS
PLUMBING PERMIT FEE
¢E_Oo the.basis for the alleged exemption.Any violation ofSection 703 L5 STORIES TYPE CONSTR.
aim by any applicant Ax a permit subjects the applicant o a civil pen:dty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(f500).):
❑ I,as owner of the property,or my employees with wages asBACK FLOW PROTECT. DEVICE +2.00 OCC.GROUP RES.UNITS
(herr sole compensation,will do the work,and the structure Is not
intended or offered for sale (Sec. 7044, Business and ProfessionsDRAINS-FLOOR,ROOF,AREA,CON D. 4.00
Code:The Contractor's License Law does rot apply to an owner of "
property who builds or improves thereon,and who does such workFIXTURES-PER TRAP 4.00 - Sa FT.FLOORAREA TOTALACREAGE
himself or through his own employees,provided that such improve-
r ents are not intended or offered for sale,If,however,the buildingGAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- -EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. - 20.00
IT 1,a owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to 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 - -
.o an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
cine Crus for suchceneLwith ac.ntrvcror(S)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the Casts to such
License Law.
❑ I:rt exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS•COMPENSATION DECLARA'RON WATER TREATING EQUIP. 4.00
I hereby affirm that 1 have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a Beat ifed
copy there. ($,c� �3__800,Lab.C.I. -
P.(ICV
No I"Company_SEu - %d-b$E
0 ❑ jj.crtitiedy is hereby f shed FIRE SPR INK ENERGY T 24
fsVCertil ie cu file w th Ci m action division.
Z'p Applicant- I MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N
F- y - PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.0 C.
CER'1'IPICA'I'MPE SAA ION INS P OM WORKERS'
W COM out be I'I..INSURANCE the' PLc.corvTR. LIC.NO. PLG. ' Y❑ .N❑ Y❑ N❑
d O (This cation $10 not hu complctcd if the'pennit is (or one TOTAL
0Z hundred dollnrs(EI00)or less.) - -
U O 1 certify that in the performance of the work for which this per- FEE SUMMARY
W H mit is issued,1 shall not employ any person in any manner so as t. QTY. MECHANICAL PERMIT, FEE
U become subject to the Workers Compensation Laws of California.
0 ED Date Applicant ALTER OR ADD TO MECH. 4.00 . BUILDING
} ED NOTICE TO APPLICANT: If,after making this Certificate of F.-
Z_ emption,you should become subject to the workers Compensation APPLIANCE ' 'f 111vI rlv I_ 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shill be deemed revoked. AIR HANDLING UNIT(TO 16000C.F.NL) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER)10=C!F-M.Ir5.00 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.L ,. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Nam HEATING UNIT(OVER'100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
r 1 certify that I'haveread this 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 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( EE FEE SCH. MECHANICAL ✓V
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- TO ORD.
Cupertino against liabilities,judgments, costs and expenses which ♦ - CONST.TAX
may i any ay ace, crest said City in consequence of the 1 I SUANCE -3.0
gmnl g f 11 pe LL MECH.CONT. LIC.NO. - MECH.
(/lQ� TOTAL . OLO TOTAL
Signet_. i Contractor Uatc
OFFICE COPY