6131 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI DING PROJECT IDENTIFICATION - PERMIT NUMBER
R...ING I/ APPLICATION & PERMIT 6131
p/�55 _ /J
UILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S ` � PLAN CHECK VALIDATION
NAME ` ?TV. ELECTRIC PERMIT FEE
e
CLOITNp.TCRRa ZCOCP CCD UTLETS-SWITCHES-RECEP 5.00/1.00
pM
�- 1/Nk�ft1 LIc.NO. LIGHTING FIXTURES 5.00/1.00
CONTRACTORS -f 3�� Iryld PPLIANCES-RESIDENTIAL 4.00
ADORES$, I-1 b u
35'-� Ys/Cvf PRorvE PANELS 5.00 DATE OF APPLICATION
ARCHITECTSIGNS 6OU PLAN CHECK FEE P.C.NO.
OR .
ENGINEER
uc.No. SIGNS TRANS. 3.00
AHC
ervc. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00 D (^
APPLICANTS MOTORS SEE FEE SCH. J
ADRESS -
SERVICECHANGE 10.00 /4/A
woo LICENSIi1)CONIRACfORS DECLARATION
G
to U I hereby from 'fiat I am licensed under provisions of Chapter 9 ISSUANCE DATE
as 2 m (commencing with Section 7000)nl'Division J of the Business and BLDG. ELECT. PLG. MECH.
F m z I'ro fessionx Cod- anJ my license is Nin lull force and e(fec ❑ ❑ ❑ ❑
Z,i w W LRep.Class�G-� Lic. umber o_@I
m H Uatc-J.C✓VIContractor 'L.f
a y M ,,, BUILDING PERMIT
¢ ¢wa OWNER-BUILDER IACLARA"PION INFORMATION -
wo d O MISC.- REFER TO ORD
3 u y 1 hereby al firm tlmt I am exempt Iron' the Contractors License VALUATION $/FT.
Hu04 law Far the following reason.fsec.70 1,5,Businessmd Professions PERMIT ISSUANCE 6.00
E ,Awf Code:Any city or county which requires a permit to cooc,-,,-]leq
¢ ¢ Q O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
C ¢ requires the applicant for such permit to filo a signed statement that TOTAL PERMIT TO
a c he is licensed pursuant to the provisions ol'the Can tractor's License /04,6al Law(Chapter 9(Commencin,with Section 7000)of Division 3 ofthe
4 o Business and Professions Code)or that he is extra,,therefrom and CITY. PLUMBING PERMIT FEE
¢ r- p the basis for the alleged exemption.Any violation ofSectiun 7031.5 STORIES TYPE CONSTR.
T by any applicant l'or a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars($500).):
❑ L as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do,he work,and the structure is not
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,ARENCOND. 4.00
Code.Tim Contracmr's License Law do.not apply to an owner of
property who builds nr improves thereon,and who does such work FIXTURES-PER TRAP 4.00 ,,20, SQ FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve 130
-
nLLmls are riot intended or offered for sale.If,however.the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4,00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not built)or im- RES IND CON PS Omer
Move for purpose of salt.). INDUSTRIAL WASTE INTER. 20.00
❑ 1,as owner o1'tile properly, it,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-OVER 5(EA.) 1.00
contracts for such projects with a cromrations)licensed pursuant to
the Contractor's License Law, SEWER-SANITAR V-STORM EA.200ft/8.00 •� TRACT NO. PARCEL NO.
❑ lam exempt under sec. .B.&P.C.lit this WATER HEATER W/VENT V 4.00 '3Z,6D
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKpRS'COMPISNSA'I'ION DeCLARAHON WATER TREATING EQOIP- t•` 4.00
I hereby alfrm [],at I have a certilicu,eofconstnt 1.self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,LAM1C.yI�t��
I•nlicy No. Compuny.f_Y--
Q IT Certified copy is hereby lurnishl:dsP��ll�.(,7 � - FIRE SPRINK ENERGY T24
Z z /❑ CeNiOy•}copy is r51 it the ay inspection division. MISC.- REFER TO ORD.
O- APplicxnt_(�k,.g ( .1•x,.Y� Y❑ N Y ❑ IN
t-' CI:R1Il:ICAI1 0E EKEMP'I'ION FROM WORKERS' PERMIT ISSUANCE 6.00 6, 0'a FLOODZONE A.L.U.C.
UJ >_ COMI'IiNSA1'ION INSURANCEPLG.coNTR. LIC.NO. PLG.
CL o (This section need not be completed if the permit is for one TOTAL / /0 " Y ElN❑ Y❑ N❑
02 It w1NddullarslSl0()orltss)
U O 1 certify that in the performance of,he work for which this per- CITY. MECHANICAL PERMIT FEE 'FEE'SUMMARV
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 Calilbrnia.
U u Date Applicant ALTER OR ADD TO MECH. q-BO BUILDING
> m NOTICE"FO APPLICANT: If,after making this Certificate of Ex-
F 2 caption,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 ITO 10p000.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 101ODDC.F.NL) 5.00 SEISMIC FEE
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.(:.), San TDSe HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Nam. �nn - 0�1 ^r_.If^/---.apt'? art HEATING UNIT 100,000 B.T.U.)7.50
Lender's Address-/sl O..rk ( ^.�� C- n17 A ELECTRIC
I certify 'hail have read this application and state that the above VENTILATION FAN (SINGLEI 3.00
information is correct. I agree to comply with all city and county PLUMBING , O
ordinances and state laws relating to building construction, and BOILER-COMP 13 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the 801 LER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes.
(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 mid City in consequence of the PERMIT ISSUANCE 3.00
graNingofthis permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signetu a of Applicant/Cont.Ctor ) Dale
OFFICE COPY