1294 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALI_ POINT P LY
�,•BU I LDING PROJECT IDENTIFICATI ON PERMIT,Nu BER
�• BUILDING APPLICATION & PERMIT 129
AD•�DR�ESS,. � I v -
'^�b7 l / �� BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
V _ _ _ . _ ... -
OWNER'S PLAN CHECK VALIDATION
NAME �$ �/��j�J� OTV. ELECTRIC PERMIT FEE
Gu ._ ONELSra 3:5)"to
CONTRACTORS
NAME OUTLETS-SWITCHES-RECEP 5.00/1.00
0.
NAME 3� .5 -�J
('2 [, � LIGHTING FIXTURES 5.00/1.00
l�-.)L.• LIC.N
CONTRACTOR'S Sr, PPLIANCES-RESIDENTIAL 4.00
ADDRESS
` HONEZ � PANELS 5.00 DATE OF APPLICATION
ARCHITECTSIGNS 600 PLAN CHECK FEE P.C.NO.
OR .
ENGINEER
uc.No. _ SIGNS TRANS., 3.00
AARCHOR DDRESS ENG SPECIALCIRCUIT 5.00 PERMIIT�VALIDATION
ZIP EMP.METER'OR POLE INS. 15.00
APPLICANTS
JSERVICE
RS SEE FEE SCH.
RE55 . /
�• � S CHANGE 10.00
, 00 LICENSED CON'T'RACTORS DECLARATION
< u w 1 hereby affirm that I am licensed under provisions of Chapter 9 'ISSUANCE DATE
y¢ m (Commencing with Section 7000)of Division 3 of the Basions and - BLDG. ELECT. PLG. MECH.
H w z I"Wessions Cod n ➢y license is in full for,• !� icct 7rzDw - License Clans Lie Nmnber a4 5_ YIo W H w¢ ¢ OWNER-BUILDER DECLARA'fIOR BUILDING PERMIT.
-lT[a " .- REFER TO OR INFORMATION
WI hereby affirm that I am exempt from the Conlractgrn Licen.ac -
LLo ¢ Law for the following reason.(See,7031.5.Business and professions PERMIT ISSUANCEVALUATDN S/FT.
E Code Any.city or county whicbrequiresir permit toconstnnn,alter. 6.00 G•�
�•�q I
< p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. //�a Its -�74id•
- O LL requires the applicant for such permit to file a signed statement that TOTAL �pJ- PERMIT TO
a w m he is licensed pursuant to lire provisions of the Contractor's License
F z r Law(Chapter 9(commencing with Section 7000)of Division 3 oftlle
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
r Do the basis for the alleged exemption.Any violation of Section 7031.5 ST IES TYPE CONSTR.
a, ;m by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN&VENT-WATER (EA.) 0,,00 - '-
o1'not more than live hundred dollars(5500).1.
❑ I,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
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 50,FT.FLOOR AREA TOTALACREAGE
so himself or Ihrough his own employees,provided Ihm such improve-
menu are not intended or offered for sale.If.however.the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4,00
or improvement is sold within one year of completionthe owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will hove the burden of proving that he did not build or int" RES IND CON PB Omer
proveforpurposeofsalc.). INDUSTRIAL WASTE.INTER. 20.00
❑ I,as owner of the property,Jm Cxelusivdy Contracting With ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
.,,it Professions Code:The Contractor's License Law does not apply '
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such proicros with a Con tractorto licensed pursuant to
Ric Contractor's License Law, SEWER-SANITARY-STORM EA. 200ft/8.00 TRACT No. PARCEL No.
❑ l am exempt under Sec. .B.&P.C.I'or this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACG FILE NO.
WORKERSCOMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to sellEinsure. - ZONING ENG:SITE NO.
or a cenificutc of Works,,Compensation Insunuce,or a certified
copy there (Sc,,3800,Lab.G)_
Poll =C..... V
Q ❑ C rificd copy is hereby furnished. .- FIRE SPRINK ,ENERGY Toa
Z Z r icd op+ iz filed with the city inspection division.
O _c MISC.- REFER TO ORD. Y ❑ N❑ v ❑. N❑
nnphc'
Fre ---� PERMIT ISSUANCE 6.00 FL000 ZONE A.L.u.c.
ir CER'1'II4CATIi OI'FXEMI'1'I )N pR 'ORKERS'
DJ _ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
�•0 (This section need not be completed if the permit is for one TOTAL v[:] N❑ v ❑ N❑
Z hundred dollars(5100)or less.)
(,� O ' 1 certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
L.L F unt is issued, I shall non employ any person in any Iuannur sn as to
O w become subject to the Workers'Compensation Laws of California 00
Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
}
Q. NOTICE TO APPLICANT: If,after making this Certificate of Ex-
� Z emption.you should become subject to elle Workers'Compensation APPLIANCE_ 4.00 PLAN CHECK
provisions of the Labor Code, you must torthwinh comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCITON LENDING AGENCY AIR HANDLING UNIT(OVER 10=1C.F.M.) 5.00 SEISMIC FEE •.5�
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
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Le'nder's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
O( ��
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE). 3.00
information is correcn. I agree m comply with 'ell city and county PLUMBING
ordinances and state laws relating to building coustmetion, and BOILER-COMPI3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city no enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree no save, indemnify and keep barites the City of MISC.- REFER TO ORD.
Cupertino against liabilities,jutlgmenti, costs and expenses which CONST.TAX
nlay int any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
noting of this permit. MECH.CONT. LIG NQ MECH.
�v k _�/ - - TOTAL TOTAL o�a
Signa are of Applicant/Contractor el Date -
OFFICE COPY