7099 _ ^ir
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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
ED LDING APPLICATION & PERMIT 7 99
An RE55 / lD IG /�I BUILDING-ELECTRICAL-PLUMBING-MECHANICAL / ,
OwN RS If' PLAN CHECK VALIDATION
E QTY. ELECTRIC PERMIT FEE
• / , HONE Z'
CONTRACTORS OUTLE,�S-SWITCHES-RECEP 5.00/1.00
uc.No. LIGHTING FIXTURES 5.00/1.00 ./
P'
.D A OR'sPPLIANCES-RESIDENTIAL, 4.00
[ADDRESS
PHONE PANELS 5.00 _JgXDATE OF APPLICATION
R E T SIGNS-` 500 PLAN CHECK FEE P.C.NO.
R NGINEERLOC.NoIft SIGNS TRANS. 3.00
Ir
ARCH.
D ESS ENG. - SPECIALCIRCUIT '5.00 PERMIT VALIDATION
_ ZIP TEMP.METER OR POLE INS. - 15.00 l
ADDRESST MOTORS SEE FEE SCH.
S
SERVICE CHANGE 10.00 W1 ,F
wo o LICENSED CONTRACTORS DECLARATION 93;' / a� 1�
¢ o U hereby affirm that Taco licensed made,provisions of Chapter 9 ISSUANCE DATE
vHi c N (commencing with Section 7000)of Division 3 of the Rosiness and BLD ELEC PL MECH.
,-; w z Professions'Code I my licalse is in full force and effect
z O Lice Class Lie Number
-o H Dale; Conlraclor
BUILDER DE A BUILDING- ERMIT
R 0 w - INFORMATION x`
R o A MISC.- REFER TO ORD _
w 3 u H I hereby at that I am exempt from the Contractor's License .. VALUATION E/FT.
i F u o J Law for the following reason.(Sec 7031.5,Businessand Professions PERMIT ISSUANCE / I
ut Code:Any City or county which requires a permit to construct,alter, 5'� I r f,
IS Q ¢ 0 improve,demolish,or repair any structure,prior to its iss omme,also ELEC.CONTR.'' LIC-NO. ELEC. / -
O(¢ requires the applicant for such permit to file a signed statement that, ` TOTAL (95 / PERMIT TO
a a m" he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe
< Business and Professions Code)or that he is exempt therefrom and QTY, PLUMBING PERMIT FEE
`, 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 to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not mom(Iran Five hundred dollars(S500).): J-, � II
O-I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 t \OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not ,
intended or offered for ash, Sev. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND- 4.00
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 SD.F .FLOOR AREA TOTALACREAGE
• himself or through his own employees,provided that such improve- '
in are not intended muttered forsale.If,however,the building GAS-EA.SVSTEM-11NC.40UTLET$ 4.00
or improvement is sold within one year of completion,tie owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving(hat he did not build or int- IND CDN Pe, Omer
prove for purpose of sale.). ' - -. INDUSTRIAL WASTE INTER. 20.0
❑ I,as owner of the property,am exclusively contracting with
/ licensed contractors to construct the project ISce. 7044,Business. i LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO. ;r
and Professions Code:The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon.and who LAWN PRINKLERS-OVER 5(EA.) 1.00 3-s -��- o� a
contiac(s for such projects col{li a conlractorfsl licensed pursuant[o
the Contraclor's License Law. - SEWE SANITAR V-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
❑ Aam exemprundei Sec. ,B,&P.C.for this WATER HEATER W/VENT 4.00 /
reason A
Owner Date WATER SYSTEM 4.00 Act.DAT ACC.FILE NO,
/� WORKERS'/C'�O)MPENSAI ON DECLARATION WATER TREATING EQUIP. 4.00
\ Ills q;,ifARtra 4;vu� erli�ellteoI consent to selhinsure, ZONING
or a certificate of Workeri Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.3800,Lab C.).
'olicYNo. ComParty_�JJI1 n
O ❑ Cetlilied cmpY'is hemhy furni41 PJ n d �G_ l I�!'�.a h/G '/Jr r FIRE SPRINK ENERGYT24
Z Z• Cc"ified Copy i'filed with the city inspection division. -- - -
O A t MISC.- - '- REFER TO ORD. Y 0 Np Y 0 IJ[]
CC m ' CERT IC� Eh ON FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
' W � r COMPENSATION'INSURANCE PLG.CONTR. LIC.NO. PLG. V� N� V� NE]Z'a. (This section need not.he completed if the permit is for one TOTAL
•hundreA Aollurs(5100)or lcxsJ r
U O.nn - 1 certify that in tire performance'of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued, I shall not employ any person in any mannerso as to
U become subject to the Workers'Com ensation Laws of California. �,Z'1
O w p BUILDING Vv
n Date Applicant ALTER OR ADD TO MECH. 4.00
} to NOTICE '10 APPLICANT: If,after making this Certificate of Ex-
F.. Z l emption,you should become subject to tic Workers'Compensation APPLIANCE .1.0 PLAN CHECK 'N
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 10=C.F.MJ 3.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAST HOOD(WITH DUCT) 2.00 /
the performance of the work for which this permit is issue Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO-100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Leader's address ELECTRIC
I certify that l have oneasa heti 4h tatetat the above VENTILATION FAN (SMGLE) �3f00 ` /w
. information is correct. I agree to comply with all city and county PLUMBING V� -
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 i 4
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. , p MECHANICAL �� w
(We) agree to save, indemnify and keep harmless the City of MISC.- _ REFER TO ORD. �f I
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 h CONST.TAX
may in any ay accrue against said City in consequence f the 1 /vf
granfjj)&-" his permit //(J` MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL 3 3�
Signam�icant/Contract- I Date IF
INSPECTOR COPY