5706 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATION PERMIT NUMBER
Bar LDING APPLICATION & PERMIT 5706
ADDRESS t BUILDING - ELECTRICAL-PLUMBING -MECHANICAL ( b
OW ER'S L,ILI(D- PLAN CHECK VALIDATION
NAME n _ Q QTY. ELECTRIC PERMIT FEE
s ��l'. P.f.C4o4R h IZI�
�! CONTRACTORS UTLETS-SWITCHES-RECEP 5.00/1.00
NAME
7. • 1 /bt& o. L' LIGHTING FIXTURES 5.00/1.00
CONTRACTOHS APPLIANCES-RESIDENTIAL 4.00
ADDRESS
�), PHONE _ I PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS B_00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
j {Llp.No. SIGNS TRANS. 3.00
RCH.OR ENG. I SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS r
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANT-S MOTORS SEE FEE SCH.
AGORE55 s
1"� $ fjfMECHANGE 10.00
wo a LICENSED CON'1'RACI'ORS DECLARATION 3/�/��
a, v Ca 1 hereby affirm that I ren licensed under provisions of Chaplet 9 ISSUANCE DATE
(connnencing with Section 7000)of Division 3 of the Business and SLOG_ ELECT. PLG. MECH.
iI rok sious Co t ny liens.is' lull lore.at it fie-I
z o m - L c Class I Nu ober L �I - "• �� +. !❑
o °w Dal ��_Contrucl�r S x` ..{ t �. >(• ,'(+ .'--h' " -'
m ¢ a
OWNER-BU DECLARATION -S f ar BUILDING PERMIT
a w u INFORMATION
o ra REFER TO ORD
w3 LL .- I hereby affirm that 1 am exempt from the Contractor's License MISC.-
LLoj Law for l he following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE VALUATION $/FT.
' = - Code:Any city Or County which requiresa permit to construct.alter, 6'00
Q O improve,de....+fish,m repair any,lr,,cl are,prior to it,issuance,also ELEC.CONTR, LIC,NO, ELED. iiacisq)
aS LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
m
w bo is licensed pursuant the provisions of the ContrW
ucr's License
H z i Law(Chapter 9(commenciagwilh Section 7000)of Division 3 ofthe
Q Business,and Professions Code)or float he is exempt therefrom and CITY. PLUMBING PERMIT FEE
Eio
A. ro the basis for the alleged exemption.Any applicaofSCaion7031,5 STORIES PE CONSTR.
A. ;m by any applicant Gera permit subjects the applicant m a Civil penally
of notmore,than five hundred dnlims(5500).): ALTER-DRAIN -WATER (EA.) 4.00 Ca
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 2.00 OCC.GROUP T1 RES.UNIT
Ihur sole comp n,nti n,will d0 the work,and tire structure Is not -
-, intended or, ff or d for sale.(SCc 7044, Buslbc x� dd'rofcssionS DRAINS-FLOOR,ROOF,AREA,COND. 4:00
C '
Code:The ontractor's License law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO,FT.FLOOR AREA TOTAL ACREAGE
onuplf re through his own employees.Provided that such iImildve-
memsarenot intended oroffered employees,
ar provided
sthatsihc building GAS-EA.SVSTEM.-11NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 s BUILDING USE
builder will have the burden of proving that he did not build or im-
ptm'cforpinpOFCnfsafe.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON PIS Omer
❑ 1,as owner,of the property,tun exclusively contracting with - ❑ ❑ ❑ ❑ ❑
licensed contractors In construct the project(Sec 7044,Business LAWN SPRINKLERS-I INC'5 V.B. 5.00 ASSESSORS PARCEL NO.
and professions Code: I'he Contractor's Liumse Law does nal apply
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contraclor(s)licensed pursuant to
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am xcmpt reader Sea .B.&P.C.lirr thin WATER HEATER W/VENT 4.00
I'd reason- -
Owner' ' Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE-NO
+. W([r,RKii RS'C'OMPIiNSA'I'ION DECD RATION WATER TREATING EQUIP. 4.00 '
IJ 1 hereby Ytfirnl than 1 hlavoa certificate of,.7 neat to self-insure,
or a ecrtifi to of workers'Compensation Insurance,or a certifiedcopy this ZONING ENG.SITE NO.
Policy No�( smeria '
J ,0 ❑ Certified Copy I, ierch, slmhd. , - r FIRESPRINK. ENERGY T 24
- Z Z d w Y n filed". the OitY T01 11011 Juvrsion. - �..; -ti.I _y. ., a ,- +
O Applicant ; 'A - , MISC.- ' REFERITO ORD. ' ti' :"yO _N a. y Q•.'N❑'..
( ~ w PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.uc.
CER" OF EXIiMP'I']ON PROM WORK h; S'
LU _ COMPENSA'HON INSURANCE PLG.CONTR. LIC.NO. PLG. Y N v N
d 0 (This scow. need not be completed if 0m permit is lin one TOTAL ❑ ❑ ❑ ❑
Z hundred dollars(SI00)orless.) y
U O 1 certify That in ate performance of the work for which this per- CITYMECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued.I shall not employ any person in any manner so as to
U hea+mesubject to Om Workers'Cmnpensation Laws of California.
a Dam Applicant
ALTER'OR ADD TO MECH. 4.00 BUILDING E
} EO NOTICE 10 App LICAN'1'. 11,After making this Certificate of Ex-
I_, Z enlption,you should become suhject to the Workers'Compenmlion APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must rorthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR.HANDLING UNIT(TO 10=C.F.fA) 3.00
CONST'RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10J000C.F.M.) 5.00 SEISMIC FEE , ( a
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.L HEATING UNIT IT
O 100,000 B.T.U.) 4.00
Lenders d
Lender's Add.... HEATI NG UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
dr
I certify that l 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-COMIP(3 H.P.or 100,000 B.T.U.) 4.00
hereby aulhoriie representatives of this city to enter upon the BOILER-COMP Mace 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless Hie City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expert which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
gmntiogolbuspeunit. (( MECH.CONT. LI C.NO. MECH.
(1 f
0 X10 1t. O lk� f�q � o�Co &5- OTAL TOTAL 5l I
Sign tureo Applicant/COntractor ( Date
INSPECTOR COPY