C6138 APPLICANTITO BILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LOING PROJECT I DENTI FICATI ON _ PERMIT NUMBER
BUILDING APPLICATION & PERMIT �� ��
_/ ADDRESS
T BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
If 1A0 ui; av
OWNER PLAN CHECK VALIDATION
�_1Z rvnmet -I. P� ILj\OI!_� TY. ELECTRIC PERMIT FEE .70
p
CONI ACTORS ~ L1. J 7 a 32-
E � OUTLETS-SWITCHES-RECEP 5.00/1.00 .
y OIeLI -utj '(¢Ze°o.f LIGHTING FIXTURES 5.00/1.00 �4/��✓
CONTRACTORS' I APPLIANCES-RESIDENTIAL 4.00
ACURESS �p7
pryF �`O3 PANELS 5.00 DATE OF APPLICATION
HCH ITECT / SIGNS 6.00 PLAN CHECK FEE P.C.NO.
oENGINEER 1
LIC.NO. q SIGNS TRANS. 3.00
ARCH.ORENG. / . SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
AOOREss 11J71 VSi��I�q .
zI
rrEMP.METER OR POLE INS. 15.00
APPLICANTS I CSO g y /��a�) MOTORS SEE FEE SCH.
' ADDRESS {YELL g71�N r't,V)\j fJ
p SERVICE CHANGE 10.00
O o *EICE CONTRACTORS DIiC1,A RATION `�(•�/ 0�/
M, is 'f I hereby of firm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
w a, yr (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F w z - I'mfessions Code,acid my license is in full force and effect
z o m - License Class_f_7 Lic.Number w ❑ ❑
Q to w DBLC ' a-C.-Contractor
a x _G.� BUILDING PERMIT
m wa ) owNliwBuu.DEk D¢CLnkn'flHtjl'f^7ert; INFORMATION
o a ° MISC.- REFER TO ORD
w 3 G 'I'hcreby at that I um exempt from the Contmdor's License VALUATION S/FT.
F .. o j Law for the following reason.(Sec 7031.5,ftusincu and Professions PERMIT ISSUANCE 6.00
Code a Any city o,county which requires a permit to construct.alter,ic
K Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
in
-p Ie «quires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
u
or m u _ he is,lieensed pursuant m the provisions of the Contractors License
HiQLaw(Chapter 9(commencing with Section 7000)of Division 3 oflheI� 11 i
liminess and I'rofissions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE L_
rte- o the-basis for We alleged exemption.Any violation of Section 7031.5 STORIES TVP CONSTR.
a.3m by!any applicant for a permit subjects file applicant toa civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not Inure than live hundred dollars(8500):1'.
0: 1 as owner of life property,or my employees with wages as BACK F LOW PROTECT.DEVICE 2.00 OCC.GROUP RES.unlTs
their sole compensation,will do the work,and life structure is not
intended or offered for sale (Sea 7044, Business and Profccions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 W
Code Jhe Contractor's License Law dues not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 W -SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such im
mu prove-
enare not intended or offered for sale.If.however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 4.00 s� O
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have lire burden of proving that he did riot build or int-
,Drown fill p ur,ow ofmlc.). INDUSTRIAL WASTE INTER. 20.00 El El ElEXOmer
❑'
I,as owns,of the properly,am exclusively contracting with
IiCFnsed RES IND CON contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
no Professions Code:'the Contractor's License Law does not apply
pfuu owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 3.� -•� - /�2,- lr
contracts for such projects with a coutructuds)licensed pursuant to
z Contractor's License law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
t❑ I am exempla e,Sec.�16U LF .&P.C.for thix WATER HEATER W/VENT 4.00 UL .
L' reason COHaT77
1 Owns01 19 - Dale } WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
RK Ii RS'COMPENSAt'ION DECLARATION WATER TREATING EQUIP. 4.00
I hereby Minn that I have a certificate ufconsent to self-insuire,ed ZONING ENG.SITE NO.
f or a certificate of workers'Compensation Insurance,or A certif
cap,thereof"(Scc 3800,Lab.C.)�
i Policy No. Company
ap' Kcnilicd Copy is hereby furnished. FIRE SPRINK ENERGY T 24
lz Z r D Cenhic fpy is filed with th�ily inspection division. MISC- REFER TO ORD.
F O/ Applicant- y-� Y❑ N❑ Y ❑ N❑
T, Cf RT 119CA'I'HO 'ION FROM WORKERS' PERMIT ISSUANCE 6.00 UTI FLOOD ZONE A.L.u.C.
COMPENSATION INSURANCE: PLG.CONTR. LIC.NO. PLG. Ns T'
CL f1'his Section need oat be completed if the permit is bar one TOTAL Q ` Y❑ N❑ V❑ N❑
:) Z hundred dollars IS 100)or less.)
0C'
O i certify that in the performance of the work for which this per. CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any pevon in any manner so as to
U become subject to the Workers'Compensation laws of California • yt.
UJ Late-Applicant - ALTER OR ADD TO MECH. 4.W BUILDING 1-
} to NOTICE 1"0 APPLICANT: If,after making this Certificate of fix-
FZ enfplion,you should beconm subject to file Workers'Compensation APPLIANCE 4.00 PLAN CHECK
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 10000C.F.M.) 3.00
•1 CONS'I'Rl1QlON LENDING AGENCYAIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE S J-
.'. .I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00 i
�. the performance of the work for which this permit is issued(See MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
•1 LenaName
e
Lenderrt's NamAddress 17HEATING UNIT(OVER 100,000 B.T.U. .50 ELECTRIC
I certify Thal l have road this application and stale that the above VENTILATION FAN (SINGLE) 3.00
infnrmatlon is correct. I agree to comply with all city and county PLUMBING (2.
ordinances and state laws relating to building construction, and BOILER-COMP Q H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon file BOI LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. 7
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX 3 y
may in any way accrue against mid City in co m uence of the PERMIT ISSUANCE 3.00 sd
grants his jl§miE. . MECH.CONT. LIC.NO. MECH.
IO TOTAL TOTAL 9a6 Al
g arc ul App want/ ontractor Da
' INSPECTOR COPY