7104 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
pnsss
�/J-�•,}- ?. ILDING - ELECTRICAL-PLUMBING -MECHANICAL O
DINNEEER'�1E r' J PLAN CHECK VALIDATION
NAME`/ ^;J�J� �./f}f T DTV. ELECTRIC PERMIT FEE �/
My.
• r I�GrCK-•1 1 6 PHONE 71 JZ 0d
CONTRACTORS 7/N'
NA E OUTLETS-SWITCHES-RECEP 5.00/1.00
LIC.NO. � LIGHTING FIXTURES 5.00/1.00
CON ACTORS APPLIANCES-RESIDENTIAL 4.00
Apon sss
®C/ T3PRONE - PANELS 5.00 DATE OF APPLICATION
ARCHITECT r .
SIGN$ 6.00 PLANCHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO.e1Z' SIGNS TRANS. 3.00
noon ass ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
377 -5-5730 ZIP TEMP.METER OR POLE INS. 15.00
ADDRESSTs MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00 I ((�
wo O LICENSED CONTRACTORS DECLARATION - /v/&l
¢ u U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
z w ¢N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG, MEC
F w A Professions Code 1 my license is in full fo and eITet. IhEY�phl Ih/�A�,Ip
o m - License Cla+s�Lic.Number
v, -w Dalc jl� Contractor IIAJ
F N F `
¢ y F BUILDING PERMIT
¢ ¢ w u OWNISR-BTIH DF.R DI?CLARA'I'I N INFORMATION
wo` I hereby affirm that I am exempt from Ute Contractor's License MISC.- REFER TO ORD
S o h y p VALUATION $/FT.
F .. o¢ Law for the following reason.(Sec.7031.5,Business anJ Professions PERMIT ISSUANCE �' 6.00
Code:Any city or county which requires a permit to construct,utler' - 3.�
¢ ¢ a improve,demolish,or repair any structum,prior to its issuance,also ELEC.CONTR. w LIC.N0. ELEC. //L2D,
o¢ requires the applicant for such permit to file a signed statement that TOTAL � v PERMIT TO
u w m he is licensed pursuant to the provisions of the Contractor's License
O/>
F z r
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
s. F_ by anyri or
fora permit subjects the applicant ioacivil penalty ALTER-DRAIN -WATER (EA.) 4.00 N�
of not more than fora hundred dollars(he appl: \ ✓✓✓
❑ I,as owner of the property,or my employees with wages a BACK F LOW PROTECT. DEVICE 2.00 OCC,GROUP RES.UNITS
their sole compensation,will do the 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 dons not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 50.PT,FLOOR AREA TATA ACREAGE
• - himself or through his own employees,provided that such improve- -
m �l.s are not intended or Offered for sale.if,however,the building GAS-EA,SYSTEM
Giants -11NC.4 OUTLETS 4.00
or improvement is sold within one year of completion,tire owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 uauwG USE
builder will have the burden of proving that he did nut build or int-
provefor purpose ofsale.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB Omer
❑ I,as owner of tire property,ant exclusively contracting with ❑ ❑ ❑ ❑
(tanked contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 � ASSESSORS PARCEL NO.
and PrV flew. s Code:The Cmuractor i License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.009s ��6 -Q�S J
contracts for such projects with a contractors)tic rrrid pursuant to J
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec,-,B.&P.C.for this WATER HEATER W/VENT 4.00
anion
Owncr. Date -71,41
WATER SYSTEM 4.00 - Att DATE! ACC.FILE NO.
If
/ ��JJwoRyy-e C ISN ION7pe�CLneA71oN WATER TREATING EQUIP. 4.00
1`hErctl9 of I7fO ,I e ce Ica Lt"uf runscnt to self-iItsum,
or a cerificato of Workers Comp ensa l ion I surance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800, parry . /A/ Yj9� ��
r
Policy No. Company-r
Q Certilied copy is hereby furnished. FIRE SPRINK ENERGY T-24
z ql Certifwd copy is fled with the city inspection division. MISC. REFER TO ORD.
Q' A picunl .! Y ❑ N❑ Y❑ NO
CC W CER'fI FICA 117 OF EXEMPTION FROM WORK E RS' PERMIT SUANCE 6.00 FLOOD ZONE A.L.u.C.
LU > COMPENSATION I N SURANCE PLG CONTR. LIC.NO. PLG,
CL Z (This section need not be completed if the permit is for one TOTAL -lf Y El N❑ Y F-1 NO
hundred dollars($100)or less.)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shalt not employ any person in any manner so as to
U huanne sub enation Laws of California.
W D'atc subject to the Workers'Com Applicant p BUIL61NG gv
a ALTER OR ADD TO MECH. 4.00 r
} Va NOTICE TO APPLICANT: If,after making this CeniEcate of Ex-
', 2 emption,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 10MC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE a
I hereby affirm that there is a constn¢lion lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of tlm work for which this permyy s issued(Sec. MICROFILM
3097,Civ.C.), �CC�A„� HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name _ /^"Z HEATING UNIT 100,000 B.T.U.)7.50
Lender's Address naw ELECTRIC 00
I certify that I havead(his application and state that the above VENTILATION FAN (SINGLE) 3.00
. information is correct. 1 agree m comply with all city and wanly PLUMBING
ordinances and slate laws relating to building construction. and $OILER-COMPI3 H.P.or 100,000 B.T.U) 4.00
hereby authorize representatives ins of this city to enter upon the BOILER-COMP(Over tOQIX108TU1 SEE FEESCH. q MECHANICAL
above-mentioned entiuned property tativsp of
ction purposes. --
(We) agree m save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses whichCONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
gr' (this peen Y. � / _� MECH.CONT. f� LIG NO. ' MECH.
{ C Zwh/ TOTA TOTAL 5`
Sig iatureul'iApp cant Contractor D to
INSPECTOR COPY