6106 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS Iea-1y _ 6106
BUILDING -ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
• G1 ��-� PRUNEa53'�395
CONTRACTORS UTLETS-SWITCHES-RECEP 5.00/1.00
N,r��jME"� C ��• ,4 1 D 11�
1<C7L� 'A' 5e„Jt CCS LIc.NO. LIGHTING FIXTURES 5.00/1.00
ADDNDRESS ons �`^� �� C.{15, APPLIANCES-RES 4.00
1p9-1 wxCV �t11. (Y PHONE gt,-1•ao4E� PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS - 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.NO. SIGNS TRANS. 3.00
ARCH.OR ENG, SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ADDSS
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS SERVICE CHANGE 10.00
,//i
wo o LICIiNSEU CONTRACTORS DECLARATION '7" /
Ur L, I hereby affirm that 1 am licensed under provisions of Chaplet 9 ISSUANCE DATE
aiHa
F (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
w A Professions Code,and my license is in full force aoJY e El ❑ ❑ ❑
Z o m Z License Class ;fit Lie.Number IF�
0 z F w Date (. Contractor
`a Y `7�1 " S 1':•�S BUILDING PERMIT
rz re¢ OWNER-RUILDER DECLARATION INFORMATION
a O n O MISC.- REFER TO ORD
x 3 LL I- I hereby affirm that 1 am exempt from the Contractor's License . VALUATION $/FT.
tLLoa Law for the following mason.(Sec.707L5.Businessand professions PERMIT ISSUANCE6.00 0
^
Cady.Any city or county which requires a permit to construct,alie,,
truct, A o
re Q¢Q Improve,de'moLSh.or repair any structure,poor 1°Its Issuance,OISU ELEG CONTE. LIC.NO. ELEC. (�
o ¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions of thns
e Contractor's Licee v -I
F Z i Law(ChapmT 9(commencing with Section 7000)of Division 3 of the
a Business and I'mfcesions Code)or that he is exempt thercliom and QTY. PLUMBING PERMIT FEE
re I m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
W3: by any applicant forapemtit subjectsthunapplicam toacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than fire hundred dollars($500).1:
❑ 1,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 lite work,and the structure is not
intended or offered for sale(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
- property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 Sa FT.FLOOR AREA TOTAL ACREAGE
hems li or-through h:own employees,provided that.such Improv✓
D. its arenoeintendd or offered for sub.I( Imwever,the budding" GAS-EA.Si STIE161.,:,1 INC.4,OUTLETSr400 a= . .�--1-•
•� or Improvement is'old within One year of completion,the owner, GAS-EA.SYSTEM'-OVER 4 (EA.) 1.00 BUILDING USE
indite,will have the burden of proving Unit he did not build or m- RES IND CON PB Other
prove for purpose of sole.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,um exclusively contracting with X ❑ ❑ ❑ 1:11
licensed contractors In construe the pmjecl lSeu. 7044,Rosiness 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 propeHy who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such..ejects with a[untradon,)licensed purwunt to
the Contranor License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exeiopt a rider Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner ])tire WATER SYSTEM 4,00 ACC.DATE ACC.FILE NO.
WORKI?RS'COMPIiNSA I[ON DECLARA'T'ION WATER TREATING EQUIP. 4.00
I Itechy uttirm that I have a cerlificule of con,erl to cell-insure. ZONING
or a certiticutc of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy lhcrrof(Scc 3918) Ilbf,y_
�cyTcan
Policy No.LeOS'e rp .AK1
Q ❑ Certifled copy is lie rcby fur1idur,d. FIRE SPRINK ENERGY L]4 ,
Z Z I)d.Cerlilm 'u ix filed with khe Joy inspection division.
O Applause `,'> nn PERMIT
REFER TO ORD. v ❑ N❑ v ❑ N❑
N CERAIFIICC`AI'EOP EXEMPTION FROM WORKERS
PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.C.
EL > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
Q. O ('This section need not be completed if the pennit is for one TOTAL Y❑ NE] Y❑ N❑
Z hundred dollars 151001 or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 Shull not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
U EDQ. Datc Applicant ALTER OR ADD TO MECH. 4.00 BUILDING 5(0.520
} m NONCE'TO APPLICANT: If,after making this Certificate of lis.
F Z einplion,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=17-F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10000.F.M.) 5.00 SEISMIC FEE 50
1 hereby affirm that then is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance or the work for which this permit is issued(Sec. MICROFILM
3097,Cw.C.). I HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lendeh Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that 1 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 PLUMBING
ordinances and'state laws relating to building construction. and BOILER-COUP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,0006TU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree m save. indemnify and keep harmless the City Of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
1-,An any way accrue against said City in consequence of the PERMIT ISSUANCE ,3.00
ggr,hisipcm.iL MECH.CONT. LIC.NO. MECH.
3 I TOTAL TOTAL
Signet .e of pphemUCr tmctorNA
INSPECTOR COPY