5705 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
B un-in G APPLICATION & PERMIT
AOOPEss
/ alL& BUILDING-ELECTRICAL-PLUMBING-MECHANICAL_ 5705
OWNER'a -":. . PLAN CHECK VALIDATION
NRME - 1 - G�i�.'y Y,�J}A A't.
OTV �" '""'-ELECTRtCPEflM1T •,'FEE
PHONE 1 E
CONTRACTORS UTLETS-SWITCHES-RECEP 5.00/1.00
L.C.NO,Uem
rULIC.No LIGHTING FIXTURES 5.00/1-00
-DN AcaoRs PPLIANCES-RESIDENTIAL 4.00
AoNP
'+ PHONE PANELS 5.00 DATE OF APPLICATION
APCNITE r SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OP
ENGINEER
LIc.No. SIGNS TRANS. 3.00
ARCH.OR ENG SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP,METER OR POLE INS. 15.00 PAID
APPLICANT
Aooness� MOTORS SEE FEE SCH.
'RMe F}$ '
SERVICE CHANGE 10.00 IJUN 211995
w¢ z
Foo LICENSED CONTRACTORS DECLARATION 'IAOC44 - City
C pI1ppI,1'y}{��pIIf��
a v w 1 hereby affirm that I am licensed under provisions of Chapter 9 P�� L _ 'j 7--SV- City PJDA�CEDATE
w a m (commencing with Section 71300)of Division 3 of the RosinessanA G. ELECT. PLG. MECH.
F m m Prufessions Code, nd ense is in full fur ❑ ❑ ❑
z o w- License la �- Lic.Number
o m - Date_ j `WV-Contractor. WI
FFJvBUILDINO� RMIT.a OWNER-BUILDER UHCLARAINFORMATION'
MISC.- REFER TO ORD
w u uFi I hereby allirm that I am exempt from the Contractor's License VALUATION S/FT.
u o¢ Law for the following reason(Sec 7031.5,Business and Professions 6.00
F - PERMIT ISSUANCE
,A Code:Any oily or county which requires permit to construct,alleq M
Qp a p improve,demolish,Or repair any Structure,prior to Its issuance.also ELEC CONTR. LIC.NO. ELEC. • W
u wO , reou rce the applicant for Such permit to file a signed Statement that TOTAL
m he is licensed pursuant to the provisions of the Conlracl Or's License PERMIT TO
Law(Chapter 9(commencing with Section 7000)of Division 3ofthe
14 os Business and Professions Code)or that he is exempt therefrom and, QTY. PLUMBING PERMIT FEE
¢ I- m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES PE CONSTR.
iiy any applicant for a permit subjects the applicant ton civil penalty ALTER-DRAIN -WATER (EA.) 4.00
OI not more than five hundred dollars($500).):
0 I,as than
of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the Structure is not
intended or Offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractors License Law does not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 4.00 So.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale.IL however,the budding GAS-EA.SYSTEM-I INC.4 OUTLETS 4,00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.)
builder will have the burden of proving that he did not build or im- 1.00 BUILDINGUSE
,,rove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 RE5 E ❑N ❑ D❑
❑ I,as owner of the property,am exclusively contra.ting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner o1property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts]in such projects with a cunt...tons)licensed pursmmot to
the Contractor's License Law. SEWER-SANITARY-STORM EA. 200ft/8.00 TRACT NO. PARCEL NO.
0 am exempt under Sec. B.&P.C.for This
reasonWATER HEATER W/VENT 4.00
Own.r Date WATER SYSTEM 4.00 ACG DATE ACC.FILE NO.
WORK E RS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby Afinm that I have a cerlificateof consent toself-insure,
or a certificate of Workers'Com cusation Insurance,or a cc fied ZONING ENG.SITE NO.
copy Ihere/�j�($ y�338 )�Lab.C.). (^�
I'olicY Nq�(d V,�fa11{tmy-_.s - Fd
❑ CerTT1I1T1�d c pY is erre by furaislmd.
Z Z �(.ni d co is 'fled yv{h t 'iiy mspecllou division. FIRESPRINK ENERGY T2
� O Anhlicam j'j({�J�� py2.�tC2C- .. MISC.- REFER TO ORD. Y[] NE] Y� NE]
C y CERT I FICYI'F:OI'FXUMPI']ON FROM WORKERS' PERMIT ISSUANCE 6.00
FLOOD ZONE A.LLLC.
Wa O COMPIiNSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
= Z 1"Phis seUlinn neuJ not hu cumPelud if the permit is for one TOTAL V❑ N V ❑ N
hundred dollars IS 100)or I".)
U O 1 certify that in the performance Of Bra work for which mis per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall nut employ any person in any manncrsn as to
Q Ubecome subject to the Workers'Compensation Laws of California.
G Uam Applicant ALTER OR ADD TO MECH. 4.00 BUI N c/�
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex- F /!�
F ? emplion,you should become subject to the Workers'Compensation
APPLIANCE 4AO PLAN CHECK
provisions of the labor Code, you must forthwith comply with -
U .such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000FEE
3.00
CONS'T'RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IQOOOCEM.) 5.00 SEISMIC FEE
I hereby affirm that Ihere is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
SO
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
Lender's Name
Lender',Address HEATING UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that I have read thU application and stale that the above VENTILATION FAN (SINGLE) 3.00
information n .street. I agree i Coto b with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
bea,ordinances end state laws relating to building construction.tion, and
above authorize representatives of this oily to enter upon the BOILER-COMP (Over 100.000 BTU)SEE FEE SCM.
abovrmentioncd property for inspection purposes. MECHANICAL
(We) agree to save, indenmify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE g•00 CONST.TAX
may in.any way accrue against said City m consequence of the
granting of ''permit. MECH.CONT. LIC.NO, MECH.
TOTAL TOTAL
OO
Sin re of Applicant/Contractor ale P
OFFICE COPY