5204 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMITNUMBER
am LDING /// ( APPLICATION & PERMIT - -
ADDRESS /IC IO N- poppy AL)^V BUILDING-ELECTRICAL-PLUMBING -MECHANICAL 5204
OwNEWS �^KRy xSUI KITH PLAN CHECK VALIDATION
NAME !J OTV. ELECTRIC PERMIT FEE
PHONE a .�•��
CONTRACTOR
NAME j (� ( OUTLETS-SWITCHES-RECEP 5.00I1.00
Sr9 vOR/O6E RFG. LIC.NG. 3171x536 LIGHTING FIXTURES 5.00/1,00
ADDRESS Q /IrJer Q41f Lt1Ap ,/(JV PPLIANCES-RESI DENT IAL 4.00
AJ_i OSE (A7 . PHONE /RS29 0T6 PANELS 5.00 DATE OF APPLICATION
ARRCHITECT SIGNS 6.00 PLANCHECKFEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
. ZIP rrEMP.METER OR POLE INS. 15.00 5.
APPLICANTS
ADDRESS00 .L I,vr OAK W,4V MOTORS SEE FEE SCH. /^\
OREss
S/}.v USC (!4 � ' Z9 SERVICE CHANGE- 10.00 s
O/
w o o LICENSIiD CONTRACTORS DECLARATION P -Z
G Z W I herchy u(tinn Ilial I am licensed Maier provisions of CluPler 9 ISSUANCE DATE
Icommencing with Section 7000).of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
G�to Professions CodC I license s in full fore and ef'..t. -Z ❑ ❑ ❑
o i)2 o Licensa Class '9 nql Lic.Number 11
Date Contractor
BUILDING PERMIT
X
SE
d OWNER-Bm1.Dr:R DECLARATION
X ;LL N I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
•' H LL o j Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00 VALUATION S/FT.
Code:Any city orcounty which requires a permit to construct,alter, .:3 /00
a ¢ ¢ 4o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. cyll,I rillto ¢ requires the applicant for such permit to file a signed statement that TOTAL PERMITTTAA
T .
u w $ he is licensed pursuant to the provisions ol'tire Contractor's Licenu
H z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofihc
i x o Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEIM
¢1-$ file basis for fire alleged exemption:Any violation of Section 7031.5 G ORIE TV E CQNSTR.
n by any applicant for a permit subjects the applicant loo civil penallyALTER-DRAIN&VENT-WATER (EA.) 4.00 r/BL��"�� -
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages usBACK FLOW PROTECT. DEVICE 2.00 t u RES.
their sole compensation,will do the work,and the tricot re Is not / '(14-14 -
UMTS
intended or offered for sale (Sec. 7044, Business unit Professions DRAIN$FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
t- property who builds or improves thereon,and who does such work FIXTURES-PER.TRAP 4.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for Sulo If,however,the building GAS-EA.SYSTEM•1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the Powner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
budder will have the burden of proving that did not build or ice
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 2000 RES IND CON PB Olin,
❑ I,as owner o .
f the properly,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCELNO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves(hereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/8.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ l um exempt under Sec. .If.&I'.C.for this WATER HEATER W/VENT 4,00
reason
Owner Data WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 4.00
1 hereby affirm (hat 1 have a certificate of consent to sell=insure,
or it certificate of Workers Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.L - -
Policy No. Company
❑ Cerlilied copy is hereby furnished.- ' FIRE SPRINK ENERGY T-24
Z ❑ Certified copy is filed with the city inspection division. MISC. REFERTOApplicant Y❑ N❑ Y❑ No
PERMIT ISSUANCE - 6.00
CIiRTI FICA'1'EPF SATIOTINS FROM WORKERS' FLOOD ZONE A.L.II.C.
W >_ COMI'IiNSAT10N INSURANCE PLG.CONTE. LIC.N0. " '
PLG.
d 0 ('ibis section need not be completed if the permit is for one TOTAL Y N Y N
Z hundred dollars IS 100)or less.)
L) 0 1 certify that in the performance of the work for which this pep DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL I. mit is issued,1 shall not employ any person in any manner so as to
U become suh'ect to I Workers'C,o9tpensalion Laws 0f Calif rota. i/
ED Uatc - Applicant..CLQy=O •fYA✓CKIO�IF
a ALTER OR ADD TO MECH. 4.00 BUILDING yLSL•Sa
} W ' NOTICE '1'O PIACANT: If,after making this Certificate of E.
H 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
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1Q000C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MOC.RM.) 5.00 SEISMIC FEE
1 hereby iflinn 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(See. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
i� I certify(all lave read this application and state that the aboveVENTILATION FAN (SINGLE) 3.00
information is.con-cel. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMPl3 H.P.Or 100,0008.T.U.) 4.00
hereby authorize representatives of this city to enter upon the 801 LER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purpaxs.
(We) agree to save, indemnity and keep harmless the City of MISC.- .REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 JCONST.,TAX
may In any way accrue,against said City in wnsequcnee of the
gmalingof lhis omit. x MECH.CONT. LIC.NO. MECH. ^M
� � t•S_ 21 �f TOTAL TOTALS
�ethrure Apple nt/Contmelor Date
OFFICE COPY S
-7