7064 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FI CATION PERMIT NUMBER
BUILOINr, APPLICATION & PERMIT
ADDRESS S V J_LLO PP. WY. 7064
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'Sp 1, PLAN CHECK VALIDATION
NAME 1/A�•LLD rA SNIOfJ PARk QTY. ELECTRIC PERMIT FEE
ONE
craXs
NANIE UTLETS-SWITCHES-RECEP 5.00/1.00
NAME
LIC,No. LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
'A� ,
PANELS 5.00 DATE OF APPLICATION
ARCH l Lc TSIGNS 6.00 PLAN CHECK FEF. P.C.NO.
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
AARCHESS OR ENG SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP ITEMP.METER OR POLE INS. 15.00
APPLICANrs
ADDRESS MOTORS SEE FEE SCH.
ADDRESS \U[,
SERVICE CHANGE 10.00
009
0o LICENSED CONTRACTORS DECLARATION
rt v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
waw (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F y i Professions Code,agg my license is in full force'nd a ect ❑ ❑ 11 Elz
License Class Lie.Number
f,o y F P Date-j- Contractor 4�
t p m `n a OWNER-BUILDER DECLARATION BUILDING PERMIT
_ ¢ w INFORMATION
o a ° MISC.- REFER TO ORD L
w S LL I- I hereby affirm that I am exempt fm.5 the Contractor's License VALUATION $/FT.
.;Foo¢ Law I: theity followingreason.ty wh(Su. dines usiness to
Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requirese permit to construct,alter,
a it 4 improve,demolish,or repair any structure.prior to its issuance,also ELEC.CONTR. - LIC.N0. ELEC.
La K m LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a' w he is licensed pursuant to the provisions of the Contractors License
La..(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe �/G�"T �LCC7
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE ( P
Q F the basis for the alleged exemption.Any violation ofSection 7031.5 STORIES TYPE CONSTR.
s u ;$ by any applicant for a permit subjects the applicant to a civil penally
of not more than five hundred dollars($500).): ALTER-DRAIN&VENT-WATER (EA.) 4.00
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 2.00 OCG GROUP RES.UNITS
their Side 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
Cade The 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,FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such int.ruwc-
mentsarenotintendedoroffered for Sala 1L however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) .1.00 BUILDING USE
builder will have the burden of proviP8 that he did not build or im-
prove for purposeofsale.). INDUSTRIAL WASTE-INTER. 20.00 RES IND CON Pe Omer
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec, 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORSPAHCELNO,
and professions Code:1'he Contractor's License Law docs not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contraclons)licensed pursuant to
file Contractor's License Law. SEWER-SANITARY-STORM EA. 200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPI:NSA'1ION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby atlirm that 1 have a certificate of consent to self-insure, ZONING ENG.SITE NO,
y or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800.Lab,C.I r
Policy N4 Company r wv�.G2 All r f 12(r Y
O ❑ Certified copy is hereby,ru tFff,f.t FIRE SPRINK ENERGY T-24
z Z ❑ Certit eA Day is file with cilY a pemion Aivision' MISC.- REFER TO ORD.
0 Applicant V❑ N❑ V ❑ N❑
W CERTIIHCATF'HCAT___EO iXE:MPTION FROM WORKERS' PERMIT ISSUANCE - 6.00 FLOOD ZONE A.L.U.C.
W > COM P:NSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
O (This section need not be completed if the permit is for one TOTAL v❑ N❑ Y❑ No ,
0 Z hundred dollars($1001 or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
a Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} 0 NOTICE TO APPLICANT: If,after making this Certificate of Ex-
I-' ? emption,you should become subject to(he Workers Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=421F.M) 3.00
CONSTRUCT ION LENDING,AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 5.00 SEISMIC FEE
I hereby affirm that them is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work forwhich(his permit is issued(Sec. T MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
1 certify that I have read this application and state that file above VENTILATION FAN (SINGLE) 3.00 1 .
information is correct. I agree to comply with all city and county PLUMBING
., ordinances and state laws relating to building construction, and - BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of (his city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. Z MECHANICAL
J 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 CONST.TAX
may in any way accrue aga'rlsxt Said City in consequence of the PERMIT ISSUANCE 3.00
grantingot this
MECH.CONT. LIC.NO. MECH.
_ -.0 y, TOTAL TOTAL
`/ ignamre ofA cant/CoNractor Date
INSPECTOR COPY