6965 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT6965
ADDRESSn Ip7 e
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S" � PLAN CHECK VALIDAT/ON
NAME/ //' ` 999-i p/y,/ QTY. ELECTRIC PERMIT FEE
• N 5EL PHONE
G 7
NAN4 rags UTLETS-SWITCHES-RECEP 5.00/1.00
NAME �1
T/T TrEi4Tia/G L,C.ND. y�/4/7e( LIGHTING FIXTURES 5.00/1.00
c-orvnrac7ons �,70I i``Nt,5TA jvr ST. PPLIANCES-RESIDENTIAL 4.00 /I
aooneu
PHONE PANELS 5.00 DATE OF APPLICATION
I AHCIBTECT / ' / SIGNS 6.00 PLAN CHECK
FEE �r1C.NO. s
Go
ENGINEER 1 ,
LIC.No. SIGNS TRANS. 3.00
ARCHE OR ENG. SPECIALCIRCUIT 5.00 PERMITVALIDATION
Y
ZIP EMP.METER OR POLE INS. 15.00 y..l
APPLICANT'S MOTORS SEE FEE SCH.
ADDH[55
SERVICE CHANGE 10.00 ✓)I
02 LICENSED CONTRACTORS DECLARATION
G v U I herthy armor Thal I am licensed under provisions of Chapter 1 ISSUANCE DATE f
(cam ntencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG.. ECR.
FN i I'rolessions Cole.and m license is in full(once a d eff.•et. ❑ ❑ ❑'
z 0 m - License Clacc_[� Lie Number
0 F 0 Date_/�.Q= Cont vac for.
a Y E J BUILDING PERMIT
¢ ¢ w ¢ OWNER-BUILDER DECLARATION INFORMATION
w ; I hmcby all•Inp tlua 1 um exempt from the Contractor s License
MISC.- REFER TO ORD
ry ! VALUATION $/FT.
F .. 0¢ I uw lin me I'ulloBeing reason(Sea 7031.5,tlusmas anA Prolisxions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,alter,
Q ¢¢ Euprove,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0, ELEC.
O ¢ requires the applicant for such permit to file a signed stulemmut that TOTAL PER ITTO
wes w he is licensed pursuwlt to the provisions of Dte Contractor's License
rzr
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
¢ Rusiness and professions Cade)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE -
¢ r o the basis for the alleged exemption.Any violation of Section 703 L$ STORIES PEC STR.
n 3'^ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
of nm more than five hundred Jollors(5500)J: - -
❑ I,as owner of the property,or my employees with wages as BACK FLOW 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:'1'tic Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 50.FT FLOOR AREA TOTAL ACREAGE_
. himself or through his own employees,provided[hut such imDrove-
mens are not intended or offered for Sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or inlprovemen L,s sold within one year of completion,the owner- GAS-EASYSTEM OVER 4 IEA) 1.00 ' BUILDING USE
builder will have the burden of proving that he did not build or in . - .
t. R IND CNG PB Other
prove tin purpose of sale J. INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of lite property,am exclusively contracting with ❑ ❑ ❑ ❑'
licensed contractors to construct the project(Sec. 7044,lousiness LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 SSESSORS PARCEL NO.
cod Professions Code:'f hu Contractor's License Law docs not apply
fo an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00 '
tine Co L' lie such Lice
ca with a contruclorfs] iccnmA pursuant to SEWER-SANITARY-STORM EA.200ft/B.00 TRACT NO. PARCEL NO..
the Cmtslor such
License La,
Cl l it...exempt under Sri.-,B&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner [)ate WATER SYSTEM 4.00
s. ACC;GATE ACC.FILE N0.
WORK ERS'C0)1MiNSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that 1 have a cerlificale of consent to all-insure. ZONING
or a certificate of Workers'Compensaliou Insurance,or a certified ENG.SITE N0: '
copy to,omfl Sec.3800,Lab C.r - -
Policy Na. 114Company r
O ❑ J.etll A#"IC I byfumis cd. FIRE SPRINK ENERGY T 24
z tYCenil icJ c y fi d will spec on division.
Z
Applicant_ ` `� MISC. REFER TO ORD. Y ❑ N❑ Y ❑ N❑
� N s CERTIFICA1'IS UI'1 XEMPTION I'RONI WORKERS' PERMIT ISSUANCE $.00 FLOOD ZONE AL.0 c.
LU > COI IITNSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL 0 I'1'his sect ton need not be completed if the permit is fel' one TOTAL Y❑ N❑ Y ❑ N❑
hundred dollars IS 100)or lass.)
U O I certify that In the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit isissue(], I shall not employ any person in;,ny manner no as to
U he.... e subject to lite Workers'Cmu,rusaU.n Laws of California.
U a [)arc Applicant ALTER OR ADD TO MECH. 4.00 - BUILDING
} N NOTICE '1'0 APPLICANT': If,nficr making this Ccrlil'icmc of Ex-
Z empUoo,you should become subject to the Workers'Compeluution APPLIANCE 4.00 PLAN CHECK
provisions of lire Labor Code, you must lin[hwilh comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.NL) 3.00 .
CONS'I'RuCNON LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE
Thereby affirm [hal there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ.C.). I _ _
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and slate laws relating to building'construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authors, representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTUISEE FEE SCH. MECHANICAL
\ above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of misc.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX �)
,no any way accrue against said City In consequence of the )
gran mg sl'it pennir. MECH.CONT. LIC.NO. MECH.
a 00 /Ay ,L� r�'� /�11 TOTAL 7.oc TOTAL
Signature of Applicant/Contractor Ute / I T rI LITTI IL�p Q qQ
INSPECTOR COPY