5043 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ON_L-Y�
r
BUILDINGPROJECT IDENTIFICATION PERMIT NUMBER
JuL.IN: / /� APPLICATION & PERMIT 5043
A ^ ,.l
?'Wk0 VgIle C01-ceq L1s. BUILDING - ELECTRICAL-PLUMBING-MECHANICAL t,} 3 ,4
.OWNER'S PLAN CHECK VALIDATION
RHGNE973-�D OTY. ELECTRIC PERMIT FEE -
PAIL)
CONTR/. TORS
NAME 'qr !hLL G 5� YCOUTLETS-SWITCHES-RECEP 5.00/1.00
0.2y LIGHTING FIXTURES 5.00/1.00 JUN 2 n
CONTRACTORS
ADDRESS - APPLIANCES RESIDENTIAL 4.00 O ����
/ ,/
O Oa O �}' �r1 SHONE `1 i -727 PANELS 5.00 C/ ON
ARCHITECT I SIGNS 6.00 PLAN CHECK C.NO.
OR
ENGINEER
uc,Na. SIGNS TRANS. 3.00
ARC H.OR ENG. - PERMIT ALI A ION
ADDRESS � SPECIAL CIRCUIT 5,00
ZIP EMP. METER OR POLE INS. 15.00 *IANCE
ADDRESS MOTORS SEE FEE SCH.AooREu ' SERVICE CHANGE 10.00
o o LICENSED CNNI'RACTORS DECLARATION
u I hereby affirm that I am licensed under provisions of Chapter') DATE
1° (commencing with Section 7000)of Division 3 of the Business and BLDCA EL CT. PLG. MECH.
mi Professions Code,and my license is in full force a eft cd. ❑ ❑ ❑
Z O V, Liceme Class C-/o Lie.Number 3eZ
o z H w 'Date 2�Z L�p�Cnn[ractnr
Q y s BUILDING PERMIT
ec Is, w¢ OWNER-BUILDER UECLARArION INFORMATION
p u O MISC.- REFER TO ORD
w ; w to I hereby affirm that I am exempt from the Co unieu is License VALUATION $/FT.
Fwpj Law for the fo0owingrcawo.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00
permit
Code:Anycity orcounty which requires a peit to construct,alter, 9
Q Q Q improve,demolish,Or repair any Structure.prior to Its issuance,also ELEC.CONTR. LIQ NO. ELEC.
p ¢ requires the applicant for such permit to File a signed statement that TOTAL PERMIT TO
w $ he is licensed pursuant to the provisions of the Contractors,License
HiQ Law(Chapter9(commencing with Section 7000)of Division 3 of the
z p Business and Professions Code)or that he is exempt therefrom and GTY. PLUMBING PERMIT FEE -
¢ r$ thebasis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i ; _ by any applicant for a permit subjects the applicant ma civil Penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars($51X7).1: -
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEV ICE 2.00 DCC.GROUP RES.UNITS
their sole compensation,will do the work,and the struetine is not
intended or offered for sale (Sec. 7044. Business and Troficssions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code: I'lie 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 tllmugh his own employee,provided that such improve- GAS-EA.SVSTEM-11NC.40UTLETS 4.00
mends are not intended cm offered for sale.If,however,the building
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 proving that he did not build or im- RES IND I'IN PB Omar
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ 1,as owner of me property,nut ucludvcly correcting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044.Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSOR CEL NO.
and Professions Code:The Counselor'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 foreochcenjeaawithacontractor(sl licensed purxlam to SEWER-SANITARY-STORM EA.2DOft/8.00 TRACT NO. PARCEL NO.
the trfor s s h projects
nse Law.
❑ lam exempt tinder Sre. .B.&P:C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00' ACC.DATE -ACC.FILE NO,
WORK BRS'COMPF NSA IION DBCIARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to wlhinsure, ZONING
or a Certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
X copy(hereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby l iunished, FIRE SPRINK ENERGY T 24
D Cc it fey1I } the yy Ins antro, division.
z APIP can r J w,(�I'(Ii tti^ MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
fZ rn CERTIFICAT OI:EXEMPf10N FROM WORKERS' PERMIT ISSUANCE 6.00 El FLOOD ZONE A.L.U,G.
11.1 �_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ NE] v ❑ N❑
CL o (This section need nni heycompleted if the permit for nm, TOTAL
Z hundmJduIIaO(SIO0)orlc.a.)
U O 1 certify that in the perfommnce of the work fir which this Iser- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is Laucd,I shall not employ unype'rvm in any manner Y)ax to
U become subject to the Workers'Compensation Laws of Calif ornia,
V ED DateApplicantALTER OR ADD TO MECH. 4.00 BUILDING
} rn NOTICE TO APPLIC M: If,after making this Certificate of Ex-
? emption,you should become subject to the Workers'Compensation APPLIANCE - 4.00 PLAN CHECK
provisions or the Labor Code, you must forthwith comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,0XIC.F.M.) 3.00 ��jj
CONSTRUCTION LENDING AGENCY AIR HANDLINGUNIT(OVER10=C.F.M.) 5.D0 SEISMIC FEE / O
I hereby affirm that there is li construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work forwhich this permit is issued(Sec. MICROFILM
31797,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
I ce Iify that l have read flus appli,,lity,an l la,that IIIc above VENTILATION FAN (SINGLE) 3.D0
information correct I agree tcomply with all icy and county PLUMBING
ordinances unJ state laws relating to b tl
mutumnion. and BOILER-COAT(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Onr 100,000 BTU)SEE FEE SCH. MECHANICAL
above mentioned properly for inspection purposes. _
(We) agree to save, indemnify and keep hurrnless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 300 CONST.TAX
today in any ay uccn ug Ins said C in coo scqucncc of the
gr Clinthis MECH.CONT. LIC.NO. MECH.
J, g I TOTAL TOTAL 433'rl"
Signalurt of Applicant/Contractor Dale
OFFICE COPY '