6967 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU WING PROJECT I DENTI FICATI ON PERMIT NUMBER
DS /) APPLICATION & PERMIT
DG
AvREs /a'7OOr1A)Ev/LJC_ BUILDING-'ELECTRICAL-PLUMBING-MECHANIC'A,
6967
OWNERS
fr PLAN CHECK VALIDATION
NAME////r OTV. ELECTRIC PERMIT FEE +y
• `.ONeN S PHONE
NAMERncro//v''s UTLETS-SWITCHES-RECEP 5.00/1.00
'fn T Llc.No. LIGHTING FIXTURES 5.00/1.00
CONTRACTORS 77d
ADDRESS CHtSTdJUI' ST. pp LIANCES-RESIDENTIAL 4.00
PHONE _ PANELS 5.00
DHMSP DATE OF APPLICATION
ARCHITEfa f SIGNS 6.00 PLAN CHECK FEE P.C.NO ,
ENGINEER
uc.NO, SIGNS TRANS. 3.00 "
ADDRiiSS ENc' SPECIALCIRCUIT 5.00 PERMIT VALIDATION
AZIP EMP.METER OR POLE INS. 15.00
ADDRESS
MOTORS SEE FEE SCH. �� t
DRE
SERVICE CHANGE 10.00
o ¢ z
Foo LICENSED CONT RAC-FORS DIiChARA'I'[ON
<u i I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE I.
(commencing with Section 7000)of Division 3 of the Business and BLDG. PLG.
ELECT. MECH.
F se z Professions Cod¢ nA m licenu is in full force t c feel.
o i L W License Class 3 I:ic.Numbc
Uute_/• Contractor
a Y f BUILDING PERM(
¢ ¢ w a OWNER-BUILDER DI:CLARAI'ION
INFORMATION
w ;LL w I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION $/FT.'
H .. o a Law for lire following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 6.00 S
Code:Any city or county which mcmimsa permit toconstrucl alter,
2 ¢ Q 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
C , requires the applicant lo,such permit In file a signed statement that TOTAL J
IT TO
A w m hu is licensed pursuant to lire provisions of the Contractor's License
r z i
Law(Chapter 9(commeeriog with Section 700001'Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
x the hasis for the alleged exemption.Any violation of Section 7031.5 VPF ONSTR.
A to
_ by any applicant for a permit subjects the applicant ton civil penally f 7.
ofnolrt'om than five hundred dollars(5500).): ALTER-DRAIN -WATER (EA.) 4.00 {..
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 ORES.UNITS'
their sole compensation,will do the work,and lire structure is not !
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 A
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 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
r Lnts are not intended or offered forsale.It,however,the huilding GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,ire owner- GAS EASYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
t
builder will have the burden of proving that lie did not build or im - . E IND CON PB Omer
prove 1,aso neer of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑
❑ I,as owner of the properly,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 Licemm Law does not apply
to an owner of property who builds or improves(hereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractuds)licensed punuant to
ore Comrxctors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt Under Sec.-,B.&P.C.for tits WATER HEATER W/VENT 4,00
reason
Owner Date WATER SYSTEM 4.00 ACC.OATE ACC.FILE NO.
WORK It RS'COMPENSAT1ON DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workeri Compensation Insurance.or a cerlifted
copy thercof(See.3900,Lah.C.).
Polity No./j/4JAConhpany
0 ❑ CeNifiedc P hcmbylurmshed. FIRESPRINK ENERGY T-24'
z ertificd Fyo� o I•d w�ftl the rye 'n pion division.
O - fJ� She V' Cl�y��� MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
Applicant A n ,q. r N v ry
N CERTIFICA'I'1 01'I*X1 MPI ION 140M WORKERS' PERMIT ISSUANCE 6.00 rLOOD ZONE AL.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d C) flhis section need not be completed if the permit is for one TOTAL Y❑ N❑ YE], N.❑
Z hundred dollar,IS 100)or less.)
U O 1 certify that in to performance of the work for which(his per- QTY. MECHANICAL PERMIT FEE FEE SUMMARV' ;,;}.zi.
LL F mil is issued.I shall not employ any psoam in any manner SO as 1n
OW Rmmi subjcd to the Wmkcri mv
Copention Laws of California. BUILDING
n Date Applicant ALTER OR ADD TO MECH. 4.00
}.DONOTICE 'l0 APPLICANT': IL after making this Certificate of Ex-
~ Z emption,you should become subject to the Worker'Compensation APPLIANCE 4.00 PLAN CHECK )
provisions of the IaMr Code, you must forthwith comply with FEE
U such provisions or this permit strait be deemed revoked. AIR HANDLING UNIT(TO 1g000C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10DWC.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there 6 a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of(he work for which this permit is issuod(Sec. MICROFILM
3097,CimC.k HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lenders Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 1
Lenders Address ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct.1 agree to comply with all city and county PLUMBING �.
ordinances and stale laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
r
} above-mentioned property for inspection purposLS.
1 (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments,costs and expenses which CONST.TAX r'
A PERMIT ISSUANCE 3.00 Q ti-
•t s may i any way accrue gainst sand City in consequence of the
gran ng fhi coni/�t�//1 / MECH.CONT. UC.NO. MECH.
i J TOTAL
1. Signature of Applicant/Contrado Dale /T r/7 T/yG p�yo� 7,vD TOTAL
INSPECTOR COPY