6938 APPLICANT f0 FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY-
BU I LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
MAIDING APPLICATION & PERMIT
ADCRSS
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a <J RA 1 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 6938
OWNER'S PLAN CHECKVALIDATION
NAME CITY. ELECTRIC PERMIT FEE
• PHONE4
CONTRACTOR t7. II, UTLETS Sin 5.00/1.00
tARC ]TVC
= _ -uCNGHTING'FIXTURES', 5.00/1.00R'sl- l�,}��T APPLIANCES-RESIDENTIAL 400
lU1 --vHorvE - .. :-, ..PANELS. •x'500DATE OF APPLICATION
SIGNS - 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO SIGNS TRANS. 3.00
/ ARCH
ADDRESS SPECIAL CIRCUIT 5.00
ZIP TEMP.METER OR POLE INS. 15.00
APADDRESSPLI ANT'S MOTORS SEE FEE SCH.
SERVICE CHANGE JORD
0 X Z
'02 _ LICENSED CON'T'RACTORS DECLARATION
u U 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
y <H Icomhneuicmg with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F N z I'm@ssions Code, h11d my h'•Ise is in f#ARA
tai a'.t
z o m- Licens aLic.IN
❑ ❑ ❑ ❑
I o m r w - Uam Contra
a ¢ ¢ I{ OWNCR BUILDER UI: ION _ ' -t. - - ,• BUILDING PERMIT. w INFORMATION
oA ° MISC.- REFER TOw w y 1 hereby affirm that 1 am exempt from the inessacmr's License VAWATION E/FT.
LL0 ¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE .
Code Any city ar county which requires a permit to contract.alter,
o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEG
aa sr 0 LL requires the applicant for such permit to rile a signed statement that TOTAL PERMIT TO
a w m lie is licensed pursuam to the provisions of the Contractor's License /
Fzi
Law(Chapter 9(commencing with Section 7000)ofDivision 3ofthe n'tC
- a Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
r o the basis for the alleged exemption.Any violation or Section 7031.5 STORIES TYPE CONSTR.
s3m by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars($500).):
❑ 1,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
Codc'Che 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 so.Pr.FLOOR AREA TOTALACREAGE
himself or through his own employees,hprovided that such improve- -
t .merits are not intended or offered for sale.If,however,the building GAS-EA:SYSTEM-1 INC.4 OUTLETS 4.00
!' or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 IEA) 100 BUILDING USE
builder will have the burden of proving that he did not build or im- . . .
RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER:- 20.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ Q. ❑
.licensed contractors to construct the Project(Sec.7044,-Business .. LAWN SPRINKLERS-1 INC5 VSB. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts
for
such
s mor,:Io,',Liceense Law. pursuant projects with a coniructorfs)licensed to
the CSEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 4.00
reason _
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORRIiRS'COMPIiNSA'I'ION DECLARATION WATER TREATING'EQUIP. 4.00 +.�.-y, .
I hereby affirm that I have a certificate of consent to self-insure. !' 'g r ZONING
hr a rllheatc r Work Comp nvI n Insuran� r a eerti icd ENG.SITE NO.
nv❑h b '
Policy Ne (,a � -
(] ❑ �fjylr ile ct 60. yfum shed. ;. FIRE SPRINK ENERGY T4<
" z.2; -✓yGuro a y�I�r��x ma city..m-p u;o h;divis Fe- ' MIS -' `" '^ ^-•'•'^--'REFER TO ORD
O API I" 'nl h1EJC _ .. Y ❑:J N❑' = _Y ❑ N❑
-Uy" 'GIiR '9 ATh OI'EXEMPT ON FROM WORKERS' ' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.0 C.
LL - COMPENSATION INSURANCE PLG.CONTR. EIC.NO. PLG. d' Y
CL 0 Z ❑ N❑ Y[1] NNE](T
CL his section reed nut he crompleted if the permit is for one C. TOTAL
hundred dollars(5100)or less)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL f mit is issued,I'shall not employ any person in any manner so as to
U become subject to the Workeri Compensation Laws of California.
WDam Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} to NOTICE '10 APPIACAN"r: If,after making this Cerlif cote of Ex-
emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
Provisions of the Labor Cade, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10f10011F.M.) 3.00
CONSTRUCTION LENDING AGENCY' AIRHANDLING UNIT.(OVER 10MC.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency Dor 'EXHAUST HOOD (WITH DUCT)" 2.00
(he 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
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 13.T.U.)7.50 ,ELECTRIC
I certify that l have read this application and state that theabove VENTILATION.FAN (SINGLE) 3.00
information is correct. I agree to Comply with all city and county PLUMBING
ordinances and state laws retailing to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 /
hereby authorize representatives of this city to enter upon the BOI LER-COMP(Over IOQOOO BTU(SEE FEE SCR. MECHANICAL �i?I
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 expe¢es which PERMIT ISSUANCE 3.0013,(-YlCONST.TAX
may in any way accrue against said City in consequence of the
gra i of this Permit L MECH.CONT. LIC.NO. MECH.
11+1�.zY�!Y TOTAL n TOTAL
eo pp icant ontruct e f111E { ��1.11(11� /
INSPECTOR COPY