5735 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMITNUMBER
ADREBUILDING
aoOREss/67 �/� rp��. _ __ - 5735
J / BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S A^PI - PLAN CHECK VALIDATION
NaM n�,�lyt,n✓' TlT���'O�y OTy• � ELECTRIC PERMIT �,JFEE
CF31P!!•I PNONE l�J
NAMTRACiGRsCA UTLES
5.00/1.00
A UC.NO. 7Y LIGHTING FIXTURES 5.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
aoOREss
1/n/n .vHOn PANELS 5.00
GATE OF APPLICATION
ORRCHnECi SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
nooRRGSS ENG' SPECIALCIRCUIT 5.00PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANT'$
nppRE Ss 1� �J p,,. MOTORS SEE FEE SCH.
IV0. TT Qi SERVICE CHANGE 10.00
o ¢ z
r o o LICENSED CONTRACTORS DECLARATION IS
¢ u w I herebyaffirm that I am licensed under rovisions of Cha IUANCE DATE
9 ISS
N a n (con men g will,Section 7000)of Division 3 of the Businessard d l L BLDG. ELECT. PLG. MECH.
F y z 1'rofcssions Cod-,v y liccnsc n in full fo •' w(� ❑ O ❑ ❑
z o m- License C ass_l(SSry. Lic.Number
0 H - Uate r)rM Contractor J-
IZ/
¢w` iJJle/��l ` ro
¢ OWNER-BUILDER DECLARATION ��- 11 BUILDING PERMIT
A °` O MISC.- REFER TO ORD INFORMATION
w g LL N 1 hereby affirm [hat 1 am exempt from the Conhaclor's License
to u o j Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE - VALUAn ON $/FT.'
fmw Code Any city or county which requires a permit to construct, 6.00 R �
Q ¢ ¢O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO.,
ELEC. V/
O ¢ requires the applicant for such permit to file a signed statement that TOTAL
a w m a- he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
H z a Law(Chapter 9 fcorrlmencing with Section 7000)of Division 3otthe Er�Q
i O Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
ce H o the basis for lire alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
La by'any applicant lot a permit subjects Ore applicant to a civil penally ALTER-DRAIN -WATER IEA.) 4.00
t
.Fact more than five hundred dollars($500t): G�
❑ I,as owner of the Property,or my employees with wages as BACK FLOW PROTECT.DEV ICE
[heir sole contpensntion,will do the work,and the structure is not 2.00 OCC.GROUP RES.UNITS
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 4.00
Code: The Contractor's License Law docs not apply to an owner of
. property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4,00 SD.FT.ELOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsare not intended or offered for sale H,however.the building GAS-EA.SYSTEM-11NC.40UTLETS 4,00
or improvement is sold within one year of completion, the owner GAS-EA.SYSTEM-OVER 4 IEA.) 1.00
builder will have the burden of proving that he did not build or iso- BUILDING USE
prove for purpose ofsule')' INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB Omer
❑ I,as owner of the Properly,um exclusively contracting with
licensed contractors to construct the project ISec. 7044,Business -SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:I he Contractor's License Law does not apply'
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts lin such Projects with a contraetono licensed pursuant to
the Coninclor:v Liccruc Law. SEWER-SANITARY-STORM EA.20011/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.RP.C.for alis WATER HEATER W/VENT 4.00
OwG`r [)are WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORK E RS'COMPENSA'TION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby alfinn [hat 1 hove o certificateol'consent ,,Self-insure,
ora ertificale sf .4'Comp msminn Inanunce,or a certified ZONING ENG.SITE NO.
,op Y them,�pp��I�( ,Lab.C.).
I' � Qnnpany-
C-rtilicJ copy is hereby) fish• FIRE$PRINK ENERGY T44
Z Z ❑ Cemfic op is Ii Cd th the airy inspection division.
� O Appllcmn_ KCAL MISt
REFER TO ORD. Y � NEI Y ❑ N�
DC w CERI'1FICAI'E OP EXEMVFION FROM WORKERS' PERANCE 6.00 FLOGO ZONE A.L.UX.
LU > COMPIiNSATION INSURANCE PLG.CONTRLIC.NO. PLG.
CL ❑ (This helium need nor be completed if the permit is for one TOTAL Y NC] Y D NC]
� Z hundred dollars IS 100)or less)
U O 1 cern[, Wet in the performance of the work for which this per. QTYCHANICAL PERMIT FEE FEE SUMMARY
IL I- mit is issued,1 shall not employ any person in any manner so as to
Q ULot become subject to rite Workers'Compensation Laws of California.
B, Dan Applicant ALTDD TO MECH. q-00 BUILDING
} Z NOTICE'10 APPLICANT: If.after making this Certificate of E.-
F. - common,you should become subject to the Workers'Compensation APPLIANCE 4.00
r isions of the Labor Code, PLAN CHECK
such you neem) forthwith comply with
U such provisions or this permit shat[be deemed revoked. - AIR HANDLING UNIT(TO 10/100CF.M.) 3.00 FEE
CONSTRUCTION L17NDING AGENCY AIRHANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE e 3
I hereby affirm 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(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATI NG UN IT(OV E R 100,000 B.T.U.)7.50 ELECTRIC
I certify that 1 have read(bis application and state that the aboveVENTILATION FAN (SINGLE) 3.00
i rfornwtion is Correct 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the
a801 LER-COMP(Over 100,000 BTU)SEE FEE SCH.
above-mentioned property Rn inspection purposes. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
grand 'of this per iL �� MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signa[urc of APplicenyt-ontrxctor IvJ arc
OFFICE COPY