5675 I
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
_ BUI LD1 NG PROJECT DENTI FICATION PERMIT NUMBER
x aD,LDING APPLICATION & PERMIT
ADDRESS
loV35- .0. n� v : BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 5675
OWNER'S ✓ PLAN CHECK VALIDATION
NAME ��
OTY. ELECTRIC PERMIT FEE
PHONE
CON croRs _ OUTLETS-SWITCHES-RECEP 5.00/1.00
NA
TwAY
CQ /,IN` uc.NO LIGHTING FIXTURES 5.00/1.00
GONTRACTOR's PPLIANCES-RESIDENTIAL 4.00ADDRESS
- -
' vnonE JfjJpPANELS 5.00 DATE OF APPLICATION
RCmTECT SIGNS - 500 PLAN CHECK FEE .NO.
OR ,
ENGINEER
LIc.No. SIGNS TRANS. 3.00
ARCH.Os ENG. SPECIALCIRCUIT '5.00 PERMIT VALIDATION
ADDRESEMP.METER OR POLE INS. 15.00 ('
APP."ANT'S MOTORS SEE FEE SCH. J
ADDRESS
- SERVICE CHANGE 10.00
00 LICENSED CONI'RACfORS DECLARATION
a u I I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
m<w (contmenrang with Section 7000)of Division 3 of the Husiness and BLDG. ELECT. PLG. MECH.
F N z Professions C a my license is in full fur e '
z o,A- Linn.Class Lic.Number El ❑ R E]
o z F j Datc__ �1 Contractor
BUILDING PERMIT
¢ ¢ n a OWNER-HUILDIiR I)IiCLA RAI'1 N INFORMATION
w r I hereby afOrm that I am exempt from the Contractor's License MISC.- REFER TO ORD
VALUATION SIFT.
r Hm j law far the following reason.(Sec.7031.5.Rosiness and Professions PERMIT ISSUANCE -5,00
> � Code:Any city or county which requiresa permit toconslmC Lefler, ELEC.CONTR. LIG NO.
¢ au ¢O improve,demolish,or repair any structure,prior to its issuance,also ELEC.
O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
whe is licensed pursuant to lire provisions of the Contractor's License
Hi> Law(Chapter9'(commencing with Section 7000)ofDivision 3 ofthe PL UM
EE
a Business and Professions Code)or that he is exempt therefrom and OT PLUMBING PERMIT FEE
3 D
¢ I- � the oasis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d ; _ by any applicant fora permit subjects the applicant(..civil penalty - ALTER-DRAIN& VENT-WATER (EA.) 4.00 '
of nor more than five hundred dollars(5500),I
❑ I,as owner of the Properly.or my employees wish wages as BACK FLOW PROTECT. DEVICE 2.00 DCC.GROUP RES.UNITS
,heir sole compensation,will do the work,and the structure Is not
intended or Offered for sale(Sec 7044, Business and Professions Z DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Coda:The Contractor's License Law don not apply to an owner of
property who builds or improvLs thcreim,and who don such work FIXTURES-PE 4.00 sG.Fr.FLooR AREA TOTALACREAGE
himself or through his own employees,provided that such improvu-
r � uterus are not intended.,offered for sale.It,however,the building GAS-EA.SVST M- C.4 OUTLETS 4.00
ur improvement u told within one year of cotnplclio0.the owner- GAS-EA.S E - V 4 EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or ice- RES ' IND CDN PR Oma
prove for purpose of sale.). INDUSTRI L EIN 20.00 El 0 ❑ ❑
CI I,as owner of the prop.rly,am cxchtsively contrachug with
lice used conlrxcturs to conslrucl the project(See 7044,Business , LAWN SPRI V.B. 5.00 ASSESSORS PARCEL NO.
nn I Professions Code:I'he Contractor's License law does not apply
to an owner of po,'"y who builds or improves l ad.n,and who LAWN SPRI S- VER 5 IEA.1 1.00
contracts for such projects with a contractnllsl licensed purwant to
the Contractors Licerf,c Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
O l am exempt undur Sec. ,ll'.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE___A_CG FILE N0.
WORKIiRS'COMPF.NSATIONDGCLARAI'ION . WATER TREATING EQUIP. 4.00
I hereby attinn llmt l have o ccu icatc of consent to self-insure. 64e - hjlt IV ZONING ENG.SITE NO.
or a certificate of Workers'Compenselion,fnsurance,or a certified
mpy thereof(Sea.3810,L.h.C.).-fes (I.� -L--.
Policy No. Company xT �I 'e"LI 1
0" 0 Ceuifinedcopyiahembyfumfshed. FIRESPRINK ENERGY T 24
z 2 �Ccrtifial yppy is IiIcJ vile lnc cit pe vio l�l divivun. MISC.- REFER TO ORD. EI
O Applicant_ L� V N Y N
cc N CERTI P KATE fx�OI'hKIi.M PTION I'ROA1 WORKIiRS' "PERMIT ISSUANCE 6.00 FLOOD zoIN A.L.u.c.
L COMPENSATION INSURANCE G.CON L LID. O. PLG. �j Clir
CL ('Phis �clion faced not be,completed if the permit is for one 7 TOTAL S v N� Yo No
2 hundred dollars 1$100)or less.)
U O I certify that its She perfonneoce of Ibc work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL F Inst is issued,I shall not employ any person in any manner on as to -
U become subject to the Workers Compensation laws of California.
U i Date Applicant ALTER OR ADD TO MECH. 4,00 BUILDING
} m NOfICI: TO APPLICAMI': If,after making this Certificate of E.
Z en,dion,you should become subject to the Workerrc Colnpcnmtlon APPLIANCE 4.D0 PLAN CHECK
provisions of the Labor.Code, you mast torthwilh unnply with FEE
U ' such provisions or this prod shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITI0VER 10,000C.F.M.15.00 SEISMIC FEE
I hereby affirm that 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. MICROFILM
3ff97,Cie,C.), HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lenders Nene
Lender's Address HEATI NG UN IT(OVER 100,000 B.T.U.17.50 ELECTRIC
I certify that phava read this Iapplication and slate that the above VENTILATION FAN (SINGLE) 3.00
information n correct, I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COW(3 H.P.or 1 D0,D00 B.T.U.) 4.00
•hereby aulhorize representatives of this city to enter upon the BOILER=COMP IOver 100.ODOBTUI SEE FEE SCH. MECHANICAL
r ubove-mentiorod 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
,lay.in any way acerae.against said City in consequence of the
IDS gof 1,P it., MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signature Applicant/Contractor este OFFICE COPY