7078 (3) APPLICANT TO FILL-IN INFORMATION WITHIkRED LINES - USE BALL POINT PEN-ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
.UILDING APPLICATION & PERMIT
ADRESS p.90-114q
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 7078V
OWNER'S PLAN CHECK VALIDATION-
NAME I-A94f"le"FAI PHONE✓/yl_,�/J� OTY. ELECTRIC PERMIT FEE
NAME OUTLETS-SWITCHES-RECEP 5.00/1.00
NAME
1_C.NO. {k/9 LIGHTI NG F IXTU RES 5.00/1.00
CONTRACTORS
ADDRESS 776 e e5ra' aij- Sr. PPLIANCES-RESIDENTIAL 4.00
ADDRESS
r.
- vRONE PANELS S.00 DATE OF APPLICATION
AR RITECT / SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIALCIRCUIT 5.00 -' PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
� SERVICE CHANGE 10.00 '1 /
o o LICENSED CON'I'RACfORS DECLAMATION IT//p S�J /-
a o w. I hereby affrm that I am licensed under ponvisims of Chapter 9 ISSUANCE DATE
.(commencing with Section 7000)of Division 3 of the Business and SLOG. ELECT. PLG. C
r w Pro(cssions Code, od I cense is in Cull fo¢e d cff•d. ❑ ❑ ❑
z o w - LIe n c CP ss LIc Number
o y Dat - Conlrador j �
,,,,;K,a, BUILDING PERMIT
¢ p w < v fix'OWNER-BUILDER DECLARA I ION .. ' ..-.Js.?s. 1 .r- i- ..•:..-. .; _. .
o"a MISC - REFER TO ORD INFORMATION
wg A I- 1 hereby affirm that I am exempt from the Contractor's License
u04 Law for the following r,a,cn.(See 70315.Business and Professions PERMIT ISSUANCE VALUATION $/FT.
Code:Any city or county which reyuiresa permit roconsU.cl,alter. 6.00
ar , ¢ n improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NQ ELEC.
- E Rquires the applicant for such permit to file a signed stnlement Ileal TOTAL PERMIT TO
whe'is lirensed.pursuant to the provisions of the Cnldmctor's License -
HZQ
Law(Chapter 9commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
T by'any applicant for a permit subjects the applicant Ica civil penalty ALTER-DRAIN -WATER (EA.) 4-00
of not more than five hundred dollars 65001.1:
❑ I,as owner of life properly,or my employees with wages as
BACK FLOW PROTECT. DEVICE 2.00 OCG GROUP RES.UNITS
Thcir sole a mpensatiun,will do the work,and the structure is not
intended or offered for rale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code:'rhe Contractors
License Law does ,of 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 TOTALACREAGE
• himself or through his own employees,provided that such improve-
meats are not intended or offered for sale.IL however.the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or impmvemcnI m
is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BuaowG usE
builder will have the burden of Proving that he did not build or int- RES IND CON PB Omer
prove lot Purpose of sale I. INDUSTRIAL WASTE INTER20.00
❑ h as owner o .f The property,am exclusively contracting will, ❑ ❑ ❑ ❑ ❑
In"nxd 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 License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractons)licensed pursuant or
are Contractors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lain exempt under Sea ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 {(ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00 fy�`
I hereby affirm that I have a certificate of consent to self-insure. 't "
or a eerlifZONINGcale of Workers'Compensation Insurance,or a certified ENG.SITE NO
c py Il, (S 3800 Lnh.f,) '' '
I t y r,r l/l Companr L UTc-4?/'r?a5t >>. .
Q ❑ CvrI 'I dyugY :.I by tum Shd FIRE SPRINK ENERGYT24
zeZs EJ/Cr r41- JColh, 1 filed. .ThO,cilyannspe typo:divlslml .,..ne _. _ _ _ _ :0. "._O - .O" --O.
O' ApPhcant-Sn /1. /C 040Oi �l '` MISC: REFER'TO ORD: ' ' Y N v N
CC
_�'-rn fli R'IIPICATI"Oh I:XIiMI'710N FROM WORKERS' PERMIT ISSUANCE 6.00 _FLOOD ZONE aL.uC.
LU > COMPENSATION INSURANCE PLG.CONTR;- ILIC.NO. PLG. Y N v N
CL O (This section need nut be c mmleted if the permit is for one TOTAL ❑ ❑ [:] ❑
Z hundred dollars IS 100)or less.)
U O 1 certify That in the performance of the work I'or which this per. OTY. MECHANICAL PERMIT FEE r• FEE SUMMARY
UL I- mit is issued,I shall not employ any person in any manner so as to
V become subject to the Workers'Compensation Laws of California.
ED Dare' Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} 0 NOTICE'10 APPLICANT': If,after making This Certificate of Fx-
F Z enrption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, youemusl forthwith comply will! FEE
V such provisions.,thisrm
peit shall be deemed revoked. AIR HANDLING UNIT(TO 1Q000C.F.M-) 3.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
are performance of the work for which this permit is issued(Sec MICROFILM
3097,Civ.C.). I HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)7.50
Lender's AOdress ELECTRIC
I certify Ilial I have'cud Ild'.'Plication and slate that The.hovc VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
ordlrenccs and state laws relating to building construetion, and BOILER-COMP(3H.P.or100,000B.T.U.) 4.00
Ill authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTUI SEE FEE SCH. MECHANICAL to a
above-mentioned property for inspection purposes.
(We) agree 1. Savo, indemnify and keep hannlcss the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs --s-Penscs which CONST.TAX
P a in
any way acct a against said City in consequence of the PERMIT ISSUANCE 3.00
gta ling fthi)pernut MECH.CONT. LIC.NO. MECH.
A
1•/G71L_: p /_r�a-RS �IO$� TOTAL r7 OD TOTAL `��
Signals o Applicant Conlmc r Date /Y/ ' C/1 r/�� z
INSPECTOR COPY