9338 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -'USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBERBUILDING APPLICATION & PERMIT '
ADDRESS
/DDRE55
oq toBUILDING—ELECTRICAL—PLUMBING—MECHANICAL9338
O%vrfER
PLAN CHECK VALIDATION
- '"AME 0/'q �Np{�PWf CITY. ELECTRIC PERMIT FEE
PRorvE
NAMERACiUTLETS-SWITCHES-RECEP 10.00/1.00
ri
Llc.No :70 LIGHTING FIXTURES ID-00/1.00 _
ADDRESS Rs PPLIANCES-RESIDENTIAL 4.00 pt.
444-.E PANELS 10= _
y—� , dT GATE OF APPLICATION
ARCHITECT
OR PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
NO. SIGNS TRANS. 3.00
ADDRESS E LIC.a. SPECIAL CIRCUIT 5,66 R PERMIT VALIDATION
ZIP rG:. EMP.METER OR POLE INS. 20.00 a q
APPLiDRCESS s
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 /
own LICENSED CONT'RACPORS DECLARATION TEMP.POLE 39,0011!
a u. I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
v, w (commencin ith Section 7000)of Division 3 of the Business and
z N g w' BLDG. ELECT. PLG. MECH.
F m z 1'rofessiuns Code J m license is in full force and effe
0 o hn — License Class _ Lic.Number �n ,r E3<
Z
w� 'Dalc Canlmmor
¢ Y EI��L BUILDING PERMIT
¢ o a OWNIi R-BUILDER DECLARATION LS INFORMATION
w3 1 hereby aff3rn that I am exempt from the Contractor's License MISC.— h.. REFER TO ORD
F u o a Law for the following reason.(Sec 7031,5.Businessand Professions PERMIT ISSUANCE 1AA0 OL VALUATION S/FT.
Code:Any city orcounty which requires a permit to construct.alter, ��
ac LICNO
¢ ¢ o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. . . ELEC. U
a
M¢ requires the applicant for such permit to file a signed statement that TOTAL � PERMIT TO
E
m u he is licensed pursuant to the provisions of the Contractor's License _
r r
Law(Chapter 9(commencing with Section 7000)of Division 3 of the s
io Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE /v C."
¢ h_ the basis for the alleged exemption.Any violation of Section 7031.5 ( STORIES TYPE ONSTR.
u ; � by any applicant for a lentil subjects the applicant to a civilpenalty ALTER-DRAIN -WATER (EA.) 5.00 r
of not in...e than five hundred dollars(5500).):
❑ 1,as owner of the property,ao my employees with wages us
BACK F LOW PROTECT.DEV ICE 4.00 G(.
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Scu, 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 5.00 3 /
Code:The Contractor i License Law does not apply to all owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5-00 4e1, -SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improveIF f
-
.cuts are not intended or offered for sale.If,however.the building / GAS-EA.SYSTEM-11NC.4OUTLETS J5M
or improvement is salt within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
O 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors la mminact the protect(Sec. 7044,Rasmus LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:'Phe Contractor's License Law docs not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00 r—y �..
contract,for such projectswith a contractors)licensed pursuant tr O (o
the Contractoh License Law. SEWER-SANITARY-STORM EA,200ft/1
f1, Q�0 K TRACT NO. PARCELNO.
O nWATER
l am exempt under Sec. ,B.&P.C.for this 'H ATER W/V ENT 6.00 Ao7r
Owner Date WATER SYSTEM 3.00 4L(N ACC.DATE ACC.FILE NO.
W'ORKERS'COMPI.NSATION'DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificale of consent to self-insure. TONING
or a certificate of Work,,,Compensation Insho mel,or a Certified ENG,SITE NO.
Copy thureof(Ses.3800,Lah.C.).
Policy No. Colnpany�{ 7.G�ycr
O ❑ Certified cop mrchy fur s�hi•d..
FIRE SPRINK ENERGY T24
Z_ z Q,�POtified p Is tiled wit city 'n lection division. MISC. - REFER TO ORD. r
O 'Applicant V❑ N❑ V ❑ N❑
~ �+ ��� PERMIT ISSUANCE 6. „� FLOOD ZONE A.L.U.C.
Cfi JCATIi OP EXEMPT ION PROM WORKERS'
LU D COMPENSATION INSURANCE PLO.CONTR. LIC.NO. PLG.
Z (This section need not be completed if the permit is for one TOTAL u,(%0 Y❑ N❑ Y ❑ N❑
hundred dollars(S 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT- FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner w as to
U become subject to the Workers'Compensation Laws of California. /
�� Q.Lu Dam Applicato ALTER OR ADD TO MECH. 5.00 BUILDING G C'I/
} W NO"fICE TO APPLICANT: If,utter making this Certificate of Ex-
z unpllion,you should hecome subject to the Workers'Compensation APPLIANCE 5.00 v PLAN CHECK
provisions of the Lubar Code, you must forthwith conmly with FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONST'RUCfION LENDING AGENCY AIR HANDLING UNIT(OVER 10 C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. - MICROFILM
3097,Civ.C.). HEATING' NIT TO 100,000 B.T.U.) 8.00 UL
Lender's Name HEATING NIT(OVER 100,000 B.T.U.)9.50 • ` _
Conder',Address ELECTRIC
I certify that I have read this application and sidle that the above VENTILATION FAN (SINGLE) 4.00 / &1'—
hit...nation
Ninformation is currea. I agree to comply with all city unJ comfy 'PLUMBING 4STP
:diiiatices and state laws relating to building construction. and BOILER-COMMH.P.or 100,000 B.T.U.)-6.00 7
hereby authorize representatives of this city toenterupon the BOILER`COMP lover 100,000 BTU)SEE FEE SCH. MECHANICAL 5(
.. above-mentioned property for inspection purposes.
-.� eqt
(WO agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 IN CONST.TAX
may ' accrue against said City in consequence of the
gra n t court. MECH.CONT. L170- MECH.
j TOTAL /Zz, w TOTAL 30
Jf naturto( nt/Contrac or Uatc r
INSPECTOR COPY -