4957 APPLICANT T ,=1LLIIN INFORMATION WITHIN REDLINES — USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER . -
BmLD,nG APPLICATION & PERMIT
A°°REss _ _ _ __ _ __ _ 4957 '
�O �,SD I BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
OWNER
S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
?410.,046E netif'u: E .-
CONTRACTOR'S U UTLETS-SWITCHES-RECEP 5.00/1.00
NA
6e to A'%ej LIC.no. LIGHTING FIXTURES 5.00/1.00
CONTRACTORS 'PPLIANCES-RESIDENTIAL 4.00 -
AOI SS
0' fy HONE 6 - PANELS S.00, DATE OF APPLICATION
ARCHITECT - SIGNS 6 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.no. SIGNS TRANS. 3.00 •
moo cis ENa SPECIAL CIRCUIT _ 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTSs MOTORS - SEE FEE SCH.
ADD RE /
v ,3,G' '. SERVICE CHANGE /�., ' 10.00
o o LICENSED CONTRACTORS DECLARATION - I NP PA 140
¢ uU I hereby affirm that I ant licensed under provisions of Chapin 9 "ISSUANCE DATE
h < (commencing with Section 7000)of Division 3 of the Business and ^ I - BLDG. ELECT. PLG. MECH.
H m z Professions Cale,and my license is in full fineq nil if c L 7 Y 1 ❑ ❑ ❑
Z .O,A License Class C-In Lie.Number
9 H Date )-/-u'V Contractor - '
a y a -a - - 'BUILDING PERMIT
re ¢ w I - OWNER-BUILDER Df:CLARATION - INFORMATION
a OAS MISC.— REFER TO ORD
x 3 LL - I hereby affirm that I ain exempt from the Contractor's License VALUATION §/FT.
H ac O a Law forth,following rca,.n.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00 -
Code:Any city c r ecomy which requires a permit to construct.alter, `
QQ ¢ 2 Improve,demolish,or repair an)'Stractme,prior to Its issuance,also E EC.CONTR. p LIC.NQ ELEC.
O ¢ requires the appliant for such permit to file,er signed statement that �.Q e(v ELK 3;� q Z% 'TOTAL PERMIT TO
E
he is licensed pursuant to the provisions of the Contractor's License
F a a
Law(chapter 9(ememencing with S"Imn 7000)of Dlvisionloflhc aL 7,
4 O Bunubsi and Profssiuns Code)or that he is esanpt therefrom and CITY. PLUMBING PERMIT FEE
at I- the basis for the alleged esemption'A ry violation of Section 703 L5 - STORIES TYPE CONSTR.
hy.any applicant for a permit subjects the applicant to acivit penalty
ALTER-DRAIN& VENT-WATER (EA.) 4.00
of not more than five hundred dollars(5500):):
❑ I,as owner of the property,or my cinploytes with wage.,as BACK FLOW PROTECT. DEVICE ' 2,00 - occ.GROUP RES.urvITS.
their Sale com�nsation,will do the work,and the structure is nun
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 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or o,inch his own employees,provided that Such improve.
hirtnts..mself o throuhh is Oroffered employor ees,provided
that Suhebudding GAS'-EA.SVSTEM-11NC.40UTLETS 4-00
co improvement is sold within one year of completion, the owner- GAS-EA'.SV STEM-OVER 4 (EA) 1.00 BUILDING usE
holder will have the burden of proving that he did not build or im. RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIALWASTE INTER. _20.00 El El EJEl ❑
❑. I,as owner ofthe p,,,Rypanr exclusively contracting Miles
licensed contractors 4o construct the pnq,et(Sce. 7044.Business ' LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ' ASSESSORS PAHCEL NO.
and Professions Calc:l'he Contractor's License Law does not apply -'
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a cuntructor(sl licensed pursuant to -
theContractor'sLicense Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am rxcmpl um Sec. .B.&P.C.for this WATER HEATER W/VENT 4,00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC:FILE NO.
WORKERS'COMPEN'SAl'ION DECLARATION WATER TREATING EQUIP. _ 4.00
I hereby affirm that I have a cert lflcwc at cun.ssent to s,HGInsure. ZONING ENG.SITE NO.
Or a certificate of Workers'Comlienwtion Insurance,or a certified
Copy thereof(Sec 381X),Lab C.1
Policy No. Company—
❑ Catifird copy is hereby'fu rushed. FIRE SPRINK ENERGY T 24
Z Z ,-G—Certifin o y is J-61eJ th he city inspection'division. -
O Applicim �J^ MISC.- REFER TO ORD. Y N❑ Y ❑ N❑
CC T CERTIFICATE OIs EXEMPTION FROM WORKERS. PERMIT ISSUANCE, 6.00 FLOOD ZONE A.L.tf C. .
LU > COMPENSATION INSURANCE PLG.CONTH. LIC.NO. PLG.
CL O (This section need ,or be c mpleted it the pernnit is for no, TOTAL v❑ N❑ v ❑ . N❑
2 Iwndred dollm(SI00)or IL,f o -
U O 1 certify that in the perlormance of the work for which this per CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL P: mit is issued,1 shall not employ any peon in any manner so m m
U become subject to the Workers'Compemation Laws of Calitomiu.•
yDate Applicant ALTER OR ADD TO MECH. 4,00 BUILDING I
} to NOTICE TO APPLICANT: If,after making this Certificate of fix-
Z eruption,you should become subject to the Workeri Cumpensation - APPLIANCE4.00 PLAN CHECK•
provisions of the Lahor Code, you must forthwith comply with ! FEE
U such provisions or this permit shall be deemed rovok,d. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCT ION LENDING AGIiNCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby aflims that there is a construction lending.agency for EXHAUST HOOD (WITH DUCT) - 2-00
_ the perfonnamc of the work for which this permit is issued(Sec: MICROFILM
3097,Civ.C.): HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
infornnation is correct I agree to comply with all city,and county PLUMBING
!, ordinances and state laws relating to binding construction, and BOILER-COMP(3 H.Ror 100,000 B.T.U.) 4.00
hereby aulh°riec mpresen ctivcs If Ih'm city to en eF upon the BOILER-COMP (Over 100,000 BTU(SEE FEESCH. MECHANICAL
,hove-mentioned property for inspection.purpises. _
(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
may in any way accrue against said City in consequence of the
got, Of lho permit. MECH.CONT. LIG NO. MECH.
-/-if TOTAL TOTAL
Signature of Applicant/Contracmr Date If
.OFFICE COPY