C 7255 APPLICANT TO FILLININ MATION WITHIN RED LINES— USE BALL POINT PEN ONLY
• BUILDING PROJECT I DENTIF ION PERMIT NUMBER
APPLICATION & PVMIT
_( AOOHLTDC El.�EEss BUILDING—ELECTRICAL—PLUMBING—MECHANICAL 255
1 v ID 1
-_/ OWNER'S PLAN CHECK VALIDATION
T "'ME p_T�Y1 1J1ELECTRIC PEyR�MIT FEE
PHONE ' I �.. -
vim
CONTRACTOR
NAME UT
LETS-SWITCHES-RECEP 5.00/1.00
LIC.No. LIGHTING FIXTURES 5.00/1.00 1
/ CONTHACTORs - PPLIANCES-RESIDENTIAL 4.00 -
�/ ADDRESS
r (� rNONe3 PANELS S.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.-
OR
ENGINEER LIC.No. SIGNS TRANS. - 3.00 '
PDDRESs ENG. • SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
- ;oP TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS
ADDRESS SEE FEE.SCH.
u wz) SERVICE CHANGE .10.00'
a IS z, LICENSED CONTRACTORS DECLARATION
¢u v 1 herchy mrinn that I nm licensed under pnivisionu'.1 Chapter 9 ISSUANCE DATE
H z In lannmencin with Section 7000)of Division S of the Business and
a n. 8 BLDG. ELECT. PLG. MECH.
Professions'Code;amfory license is in full for'•�pd of b'f.
Q 0 H [
'License Class Li,Num •r I ❑ ❑ .
to Datca�I �J__ContractD
BUILDING PERMIT
¢ ¢ a OWNF.R-BUILDF,R DIiCLARATION ---
A e a 0 MISC.— REFER TO ORD a INF_ORMATiION
w g LL E. I herchy affirm that I am exempt from the Contractor's License
at u m¢ Law for the following reason.(See.7031.5,Business and Professions PERMIT ISSUANCE 6.00
VALUATION .B/FT.
Code Any city or county which requiresa hermit Ioconstruct,alter,
¢ ¢n c 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. "
O u requires the applicant for such permit to file a signed statement that TOTAL - PERMIT TO
w m he is licensed pursuant to the provisions of the Conlr¢tor's License .
i
La.tChapter9(commencing with Section 7000)of Division 3 of the A, aj x".�'ws a Ks.3k-S+ .b'+s. v 'pp - y,,, gg..`a•
i— a -
Business and Professions Code)or that he is exempt therefrom and OT,qpVkT'KD''� 1fy" PLUMBING:PERM T(r" ypt 5'"s1wa FEE -
¢ r o the oasts for the alleged exemption Any vudulion of Section 7031$ aa''8 M n H 'yak. r- L,• „%%f Mx �x STORIES , TYPE CONSTR.
d '; m by any applicant for a permit subjects the applicant loo civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(8500).): '
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP PES.UNITS
their sole compensation,will do the work,and the structure is not _
intended or offered for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF;AREA,COND. 4.00 ,
Code:The Contractors License Law does not apply to an owner of -
propertywhobuildsorimprovesthereon,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- '
, nwnts are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-l1NC.4OUTLETS 4,00
or improvement is sold within one year of completion,the Owner-
builder SYSTEM. (EA.) BUILDING USE
will have the burden of proving that he did not build or int - RES IND -DON PD oilier
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 -
❑ I,as owner of the property,am exclusively contracting with ❑ ❑- ❑ Cl ❑
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-OVER 5(EA.) 1.00
contmet,for such projects with a eontraclons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I nni exempt under Sea ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Uwncr - Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK FRS'COMPENSA'T'ION DECLARATION WATER TREATING EQUIP, 4.00
I hereby affirm that I have a certificate of consent to self-insure.
or a certificate of Workers Compenselion Imurance,or a cert i(icd ZONING ENG.SITE NO.
ropy thert.f(Se, 3800,Lab.C.
Policy No. Company - -
O ❑ Cern ed copy is herebyfumishe A487Lj FIRE SPRINK ENERGY T-20
z ❑ Cer'and copy is tiled with the city Inspection division. MISC.- REFER TO ORD.
.O ApPllCant Y ❑ N❑ Y ❑ N❑
Cr w CERTIFICATE F EXEMI'IlU FROM WORKERS' PERMIT;ISSUANCE 6.00 FLOODZONE A.L.U.c.
L COM ENSA'NONINSURANCE PLG.CONTR. LIC.NO. PLOCL .
CL 0 11'h I. section red nol'be completed if the permit is for one Y TOTAL • Y❑ NE] Y ❑ N❑
bundled dollun(B100)or less.) v» A+ yYt +k yy y� rt b #48 > -.t yy .
U O 1 certify that in the pedormun •of the work for which this Per- 1'*
T 3 "';MECHANICAL PERMITi ' "'-V'r TuFEEaR �. FEE�SUMMARY
61
ly lit rs issued, I shall not employ any person In any manner so as to st ) I, , 4¢& 4 q} 5 ,
O W become subject to the Workers Compensation Laws of California. ` - - " - -
d Date Applicant ALTER OR ADD TO MECH..-:,LIF� 4.00 a BUILDING
} N NOTICE '10 APPLICANT: If,after making this Certificate of Ex-
F 2 omption,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(T MIF
.NL))L3:00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000C.F.M.) 5.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) LSO 8)2101d' ?T-7
tireperformance of the work for which this permit is issued(Sec. - MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Leader's Name HEATING UNIT 100,000 B.T.U.17.50
Cendcr's Address ELECTRIC"
I certify that l have read thisapplication and state that the above VENTILATION'FAN (SINGLE) 3.00 '
tolbnnation is correct. I agree to comply.with all city and county PLUMBING
r 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 10 enter upon the 801LER•COMP (Over 10D,000 BTUI SEE FEE BCH. MECHANICAL 1!O
above-mentioned property for inspection plirposcs. -
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. _.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE - 3.00 G� CONST.TAX
" \ may in any way accrue against said City in consequence of the
grouting Of this pertrlit MECH.CONT. LIC.NO. MECH. /�' 1)--
TOTAL U 4 • "y
�u.`107EAL •
Signature of plicant/Contractor Datc "$v° �'� '
'" - OFFICE COPY - '