5634 (4) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BU I LD1 NG PROJECT I DENTI FICPERMIT NUMBER
BUILDING i APPLICATION & P
aooREss 6'^ 17Wi't Y �J �� f - 5634
'
Y t( BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
OWNER'SPLAN CHECK VALIDATION
N,R1ME Pt,e{ ELECTRIC PERMIT FEE
E�lN
W69r m�e C�L 4I, PHONE ZSZ't 6S -
1
NAME Acrons 8 OUTLETS-SWITCHES-RECEP 5.00/1.00
• UC.NO. 1.1 ILIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S
ADDRESS rPPLIANCES-RESIDENTIAL 4.00 '
PHONE PANELS 5.00 DATE OF APPLICATION
ARRCHITECT - SIGNS 6.00 PLAN CHECK FEE P.C.NO.O -
ENGINEER
uc.No. SIGNS TRANS. 3.00 '
ADD ESSs ENG - SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANT'S
ADDR ESE MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00 ?7/4
� , e
T o LICENSED CONTRACTORS DECLARATION r
a i w I hereby affirm that 1 am licensed under provisions of Chupter 9 PAID ISSUANCE GATE
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG, MECH.
r H i Professions Code,and my license is in full force and effect. I�I
Z O m — License Class Lie.Number ,9[ 2�_ a I R
O N F w Date Contractor P 2 , 1%4
¢ ¢ w�, OWNER-BUILDER DECLARATION BBy BIINFORMATIONIT
Iaxu ;' w 1 hereby affirm that I am exempt from the Contractor's License M ISC.— OH F(x t�S C
HU0< Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00 VS�Oha 9 lie f/FT.
f w 0 E Code:Any city or county which requires a permit to construct,alter, 9 x�.ft 6i ,
¢ a, Q O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. q -3 `�" V v
DLL requires the applicant for such permit to file a signed statement that TOTAL oC Ms Q
e w m he is licensed pursuant to the provisions of the Contractor's License 1 Y`>§P 4t)bgrtino
F z a
Law.(Chapter 9(commencingwith Section 7000)of Division 3 ofthe \/
i c Business and Professions Code)or that he is exempt therefrom and OW. PLUMBING PERMIT FEE
¢ o the hasis for the alleged exemption.Any violation of Section 7031.5 // STORIES TYPE CONSTR.
dam — by any applicant forapermit subjects the applicant toucivil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars($500)J:
❑ 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 /3Ri M(,//Ar)4.00SD.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve
menti are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner. GAS-EASYSTEM-OVER 4(EA) 100 BUILDING USE
builder will have the burden of proving that h . . .
e did not build or im- REE IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 El ❑ 1:1 1:1 11❑ 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 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OV ER 5(EA.) 1.00
contacts for such projects with it contractors)licensed pursuant to
the Contractors License Law. SEWER-SANITAR V- A.200ft/8.00 TRACT NO. PARCEL NO.
❑ tum xempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 4400
anon_
Owner Date�J��� p WATER SVSTp�n
(—r{_b' - --e;• I' QQQ 4.00 ACC.DATE ACC.FILE NO.
WORK HRS'COAIPF-NSATION DECLARATION WATER TREA NG E UIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure' ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy therenf(Sue.3800,Lab.Cl.
Policy No. Company -
O O Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is tiled with the city inspection division. ❑ ❑ ❑ ❑
O Applicant MISC.- REFER TO ORD. Y N v N
U+ PERMIT ISSUANCE 6.00
W — CERTIFICATE PE EXEMPTION FROM WORKERS' G PL00D ZONE A.L.U.C.
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. �1
d O (This section need not be completed if the permit is for one TOTAL C�4 Y❑ N❑ Y ❑ N❑
Z hundred dolErs(S 100)or lass.)
U O 1 certify that in the performance of the work for which this per, CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued.I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
O W' Dat. ' ApplicantBUILDING
} rail NOTICE TO APPLICANT: If,after making this Certificate of Ex ALTER OR ADD TO MECH. 4.00 `-�
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
(� such provisions or this permit shall be deemed revoked. - AIR HANDLING UNIT(TO 10MC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER.10=C.F.M.) 5.00 SEISMIC FEE a73
I hereby affirm that there is a construction lending agency for I EXHAUST HOOD(WITH DUCT) 2.00
the Performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). t HEATING UNIT(TO 100000 B.T.U.I 4.00
Lender's Name HEATING UNIT(O ER ; OO B.T.U.17.50 ELECTRIC
Leader's Address
I certify that I have read this application and state that the above VENTILATION FAN (SING_L n 3.00
Information is correct, I agree to comply with all city and county LU MBING
ordinances and slate laws relating to building construction,and / BOILER-COMP(�jlLl ,Of o0',0 .T.U.)'4.00
hereby authorize representatives of this city to enter upon the BOILER COMP (Over 100,000 BTU $El HaFFEE BCH. MECHANICAL F'
above-mentioned property for inspection purposes.
LRS (We) agree to save, indemnify and keep harmless the City Of MISC. CI Y O R R 0 ORD. -
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.0 �' CONST.TAX
may in any way accrue against said City in consequence of the
graanti'nggy l�hGpeer)mi�t �' MECH.CONT. LIC.NO. MECH.
7�II�Q� TOTAL � TOTAL
Signature of Applican tjCon tractor Date
.f OFFICE COPY -