6855 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 6855
noon ss
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNEn'S /OI� I q_ 1 / PL{aN CHECK VALIDATION
NAME V M 1 IM' Ils•�/ QTV. ELECTRIC PERMIT FEE er f
• m. an PHONE
CONTRACTORS UTLETS-SWITCHES-RECEP 5.00/1.00
f ME p
wafi dr- - ( LIC.No. �0 LIGHTING FIXTURES 5.00/1.00
TRV/
CONTRACTOR
ADDRESS
Qat// A//� PPLIANCES-RESIDENTIAL 4.00
CON •//; r
7 PHONE �l •S) PANELS 5.00 DATE OF APPLICATION
ORCHITECi SIGNS 6.00 PLAN CHECK FEE P.C.NO.\
ENcwcER LIC.ND' SIGNS TRANS. 3.00 V
ADDRO .ESS ENG
SPECIAL CIRCUIT 5.00 PE ATION
zip TEMP. METER OR POLE INS. 15.00 AUG`
APPucnrr'S MOTORS SEE FEE SCH. 1985
ADDRESS
SERVICE CHANGE 10.00 C4
wa: z LICENSED CONfRAC1lRS UReffjp0T
a 02
L,U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
In 4 w (commencing with Section 7000)of Division 3 of the Business anJ BLDG. ELECT. L MECH.
H w z Professions Cod•,and my It RC is in full force and Ice ❑ ❑
z o w - Licerlsc lose • ", b LIC.Number-
Q w l2 Uutc^A - Cootacmr v
a y - V Ntc / Titl BUILDINGPERMIT
a w e, OWNER-BUILDER DECLARATION( INFORMATION
oA - MISC.- REFER TO ORD
K
u I- I hereby affirm that 1 am exempt Irom the Contractors License VALUATION / $/FT.
F LL o s, Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 6.00
Code:Anycity orcounty which requires a permit to construct.alter,
QQ Q Q improve,demolish,of repair any structure.prior to its issuance.also ELEG CONTR. LIG NOL ELEC. ( -
- D u requires the applicant for such permit to file a signed statement that TOTAL ERMIT TO
wm he is licensed pursuant to the provisions of the Contractor's License
r _i
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
a lousiness and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
oo the Innis for the alleged exemption.An,violation of Section 7031.5 5 DRIES TY7 CONSTR.
by any applicant tura permit Subject.,Dm applicart to.civil penalty ALTER-DRAIN&VENT-WATER(EA.) 4.00
of not mom than five hundred dollars(5500).): '
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
v 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
Cody.The Contractors License Law does not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 4.00 SO.FT FLOOR AREA TOTAL ACREAGE
himself ethrough intends witemployees,Far sale.
If,edve,nn,such implove-
ding GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
onto are not intended or thin on for sale.If•mpleveq the building
or improvement is Soso within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BuaO G sE
builder will have the burden of proving that he did not build or ire- RES IND C N PR Oma
prove Do purpose ofsale.). INDUSTRIAL WASTE INTER. 20.00
❑ I.ass owner o
ner of the property,am exclusively contracting with ❑ ❑ ❑ ❑;
,licensed contractors to construct the project ISev. 7044.Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS CEL NO.
and Prufcsions Code; I'he Contractor's License Law does not apply f
(I an owner o1property who builds or improves thereon,and who LAWN SPRINKLERS'-OVER 5(EA.) 1.00
contracts for such projects with a conlmctor(s)licensed pursuant to
the Contractor's License Law.
SEWER-SANITARY-STORM EA.200ft/8.00 ,pT) /TRACT NO. PARCEL NO.
❑ I am exempt Ruder Sec. .ILAP.C.for this WATER HEATER W/VENT 4.00
rcasno
Owner Dale WATER SYSTEM 4.00 ,pr ACC.D ATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate ofconsenl to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a Certified ENG.SITE NO.
copy Ihem f(Sec.380J�1l..I.A.C.). .1
PolicyNf(J CNnnpmuy t.QTAu%sf]p,[n� N.
Q ❑ Oorl ified 5gpy is 1 t furnished. FIRE SPRINK`s ENERGY T-24
v Z_ Z ❑✓E•ertifiedLf OJ.iz f�d with the city/f nspechon,divislon.
O Applicant (K:f ,�,(�l/=r Nl'[v/i' MISC.- REFER TO ORD. Y Q NE]' Y❑ N❑
PERMIT ISSUANCE 6.00 110,0-0 FLOOD ZONE A.L.u.C.
cc: CER'1'IFICAI'E OI'EXEMPTION FROM WORKERS'
LL > COMPhNSAI'ION INSURANCE P{LL CONTE. L)C.NO. PLG.
CL O (Phis section need not be Completed if the pen 1t Is for one S K[' TOTAL Y❑ N❑ Y.❑ N❑
Z hundred dollars($too)or less I
U O 1 certify that in the performance of the work r which[his per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
lL I- mit is issued,I shall not employ any person any manner so as to
V hucome subject to the Workers'Compenmtl o Laws of Califomia.
Ursa Dale Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} to NOTICE 10 APPLICANT: If,after mgl(Ing this Ce,tilicatc of Lx-
F 2 ti emption,you should become subject{d the Workers Compensation APPLIANCE 4.00 PLAN CHECK
Provisions of tire Labour Code, yo must forthwith comply with FEE
U such provisions or this permit shall ¢deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 3.00
CONSI RUC104LENDING AGENCY
AIR HANDLING UNIT(OVER I0=C.F.K0 5.00 SEISMIC FEE
I hereby affirm than ty re is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
/ tireperformancc of thl,/Work for which this permit is issued(Sec. MICROFILM
3097.Civ.C.L / HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's
Lundcr's AAdrcdde ss HEATI NG UN IT(OV E R 100,000 B.T.U.P.50 ELECTRIC
( certify th sad have read thinuppliculion and stale that'the above VENTILATION FAN (SINGLE) 3.00
• ordination correct. I agree tcomply with all city and county PLUMBING -
urJlnatne's ,is state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
Imreby/authorize representatives of this city to miser upon the BOILER-COMP lover 100,000BTU1SEE FEESCH. MECHANICAL
above-mentioned properly 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 CONST.TAX
may any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
gr' t g of thi ¢Tail. • MECH.CONT. LIQ NO. MECH. /
TOTAL
A,41 / � P/d t S� TOTAL
Signature'of Applicant/ ontructor Uate
INSPECTOR COPY