NO PERMIT NUMBER APPLICANT TO FILL IIV INFOhivIA-i IUw VVII HIN r:LD Llly :o
I BUILDING PROJECT IDENTI FICATION
BUILDING
�-]j
ACCR A,Awl,I I �ff'� •I`� BUI ��0�� Pi ��• /`/ P 1
f,OWN RS
(NAME �i ll 000
GNONE ,Y D$te
CONTRACTOR 5 1
NAME
LIC.N0. a
.ONTO
SO/(rll��4aL/t/AOOflE �
O
C' ANONE ( 1 I U
RCRCTECT
ENGINEER T' P, 2t�'❑�
(� T LIC.NO.� I SIL ErOe�
J ARCH.OR LNG, SPE.
AR E55
''.Ili' Q C e EMF
ADDRESS T MOTC ept /L
�,• SERVIL CJub, (///] 7 tOT
�oo LICENSEDCON'1'RACTORS UBCLARA'(ION n❑tee / 1 54e°
a w v 1 hereby alfinn that I alio licensed under probisimn of Chupter 9
w ATE
(commencing will,Section 7000)of Division 3.I the lousiness unJ ELECTNCE PLG. MECH.
L i Professions Code,J�d, Y liceme is in lull Imcc p Lb'I. -,S
z O w - Licensc Class Lic.Nwnber_ ���✓j� ! Pr51,
Cr N ° Date Connuelor - ea D to
¢ a w¢ OWNER-BUILDER DECLARATION 4S Ov .,BUILDING PERMIT
l'•4 , INFORMATION-
w ; N I hereby.,firm that 1 am exempt front the Cortlraetor i Licensc MISC.- -R TO ORD
u O j law for Ilse following reason.(Sec.7071.$,Business and Praessi.i6 O -� VALUATION $/FT.
r - g PERMIT ISSUA, 10.00
Code:Any city or county which requires.permil 10cunsrmcl,alter, /�� d
amu, O improve,denWlish,orrepaira.y structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O¢ requires the upplicunl I'ut such permit GO file a signed sna culcut that TOTAL
lie is litcns'ed Imrsuaul lu Ille provisions of the COnlraclui s Licenscp PERMIT TO
R Z Y
Law(Chapter 9(eonunencingwilh Section 7000).1'Division 3 of the V/4zo W
F 4 a Business and Professions Code)or that he is exempt therefrom unit CITY. - PLUMBING PERMIT FEE
OF F m the basis for the alleged exemption.Any violation Of Section 7031.5 STORIES TYPE CONSTR.
a3 �
by any implicanmore
(oro hundred
dolhirs $500).lieam loacivil penally ALTER-DRAIN VENT-WATER IEA.) 5.00 S��dti
of not more Ihun five hundred donuts(55001.1:
❑ I,as owner ol'the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not p
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply In un owner.,'
• property who builds or improves thereon,unit who docs such work FIXTURES-PER TRAP 5.00ZL:- 0OORATOTALACREAGE
hi na llor through his own employees,provided that such in,prove-
mnusurenotintendedoroll'clod for sale.it',however,llµ•building GAS-EA.SYSTEM-11NC.4 OUTLETS 6.00 . •�e:..��
or improvement is sold within One year of cmnpleti.n, the owner GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 J
" builder will have the burden of proving Ria.he did not build or Or. BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
El 1,as owner of the properly,an exclusively contracting will, 'R ❑ ❑ ID ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 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 3 -�iZG -_
contracts for such projects with a conlraclods)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt whiter Sec. '84P.C.I'.r[Ills WATER HEATER VV/VENT6.00
.son
Owney Dale / WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'CONIPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate efconsenl to self-insure,
or a Cerlififu.c of Workers'Compensation Insurance,lir a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab CT.
Policy N.. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T]J
Z Z 11Cer'- opy is filed wit the y in neo not Ji''sion.
P: LD Applicat f���ry� (,, y MISC.- REFER TO ORD. YE] N❑ Y0 N�
� N CERTIFICATE OF EXEMPTION MWORKERS PERMIT ISSUANCE 10.00 D FLOOD ZONE A.L.U.C.
LL > COMPENSATION INSURANCE PLG.CONTR. LIC,NO. pE0
CL O (This "lion need not be completed it the permit is for one TOTAL Y E N� V N�
::) Z hundred dollar,($100)or less.)
L) O 1 certify than in the peo.mo et,of the work for which this per.
QTY. ,MECHANICALPERMITI .- FEE FEE SUMMARY
0 H mit is issued,I shall e W employ any person in any injurer so is[' - F f ,
O W becmmsubject lotheWfic coq CompensufiunLawsul''California.' - BUILDING �� sa
to Nate Applicant ALTER OR ADD TO MECH. 5.00
} w NOTICE TO APPLICANT: If,after making this Cerlil'icale of Ex.
i ? emplion,you should become subject to the Workt,"'Conlpensalion APPLIANCE 5.00 PLAN CHECK
provisions of lie Labor Code, you muss l.rlhwith comply with
U such provisions or this permil shall be deemed revoked. AIR HANDLING UNIT ITO 10,OODC.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 104000.F.M.) 6.00 SEISMIC FEE �•J O�
I hereby afl'irni lhul there is a construction lending agency I'., 1 EXHAUST HOOD (WITH DUCT) 5.00 's-
tire performance 6I'me woIk..I.r which it, pormil.is issued(Sec. MICROFILM
3097,C .C.). HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
ELECTRIC 7 �1
. I certify that I have read this application and slate that tie above VENTILATION FAN (SINGLE) 4.0
information is rI agree to comply with all city unit county
qL) -
ordinances and someade l lows relating to building construction, olid BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00 PLUMBING 1AL7
hereby authorize rprtforiof this city to enter upon the BOILER-COMP Over 100,000BTU1 SEE FEESCH. MECHANICAL d
abvr
umenti.neJ property
inspection nspeclinn purposes.
(Wel agree to save, indemnify and keep Imrmlers the City Of misc.- REFER TO ORD. _
Cupertino against liabilities,judgment\, Cost' and e,pe,ses which PERMIT ISSUANCE 10.00 O CONST.TAX 9 D,S�fJ
lhlaY in any way accrue against said City in C.nscqucnce Of the 0
gmnlin of o
i5 Bni,' ECH.CONT. LIC.NO. MECH
.
TOTAL
T- O TOTAL ��76 �G
Signulurn of Ap Iiconi Cmh Ua.c ,