0834 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI.- PO PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILD14G APPLICATION & PERMIT 0834
ZADDREss
" BUILDING-ELECTRICAL-PLUMBING-MEC AL
0.NER'$ 'T i(+ v -r„ PLAN CHECK VALIDATION
NAME/ _ GTV. .'• i ELECTRIC PERMIT FEE*
l.. -PHONE p//j1✓%•� •:.: • .e a.' I
NAME"A T0R5 UTLETS-SWITCHES-RECEP 5.00/1.00S�vr
LIC,NO. 39.f526 LIGHTING FIXTURES 5.00/1.00
CONTA CTOR'S PPLIANCES-RESIDENTIAL 4.00
ADDR ss
,10 PHONE xv-/q4%/n�a
.? PANELS 5.00 DATE OF APPLICATION
ARCHITECT6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
OR SIGNS
uc.NO, SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
SS
AN el en, 7S/ EMP.METER OR.POLE INS. 15.00
APPLICANTS
ADDRESS MOTORS SEE FEE SCH. S�
X1040 9S-eiq SERVICE CHANGE 10.00
0
00 LICENSED CONTRACTOR DECLARATIONJ/-,/,a UJ H 1 hereby affirm that I am licensed under provisions of Chapter 9 TING ISSUANCE DATE
u a$ ' (commencing with Section 7000)of Division 3 of the Businessand BLDG. ELECT. PLG. MECH.
r :i Professions Code,xisr my license is in full force fear res( rVI
License CI Lic.Number J.f L/'}� 14 Li2i,
as r w Date Contractor )
S, t' T.BUILDING PERMITD.^''1`t°
o d OWNER-BUILDER DECLARATION - FER TO ORD `•��t~"-'INF,ORMATIONI)~•'' 'P
I- 1 hereby affirm That I am exempt from the Contractor's License MISC.-
LL Y D VALUATION $/FT.
a. D Law for the following reason.(Sec.7031.S.Businessand Professions PERMIT ISSUANCE 6.00
m ve Code:Any city or county which requires2 permit to construct.alter. L
e<0 improve,demolish,or repair any structure.prior to its issuance,also ELEC.CONTR. LIC.N0. ELEL.
ic m LL requires the applicant for such permit 10 file a signed statement that TOTAL $Z PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License Q.
i i Law(Chapter 9(commencing with Section 7000)of Division 3 of the s - 'L syA - ",xt% '» E I`" ' ire v`Y s FEE /
s 4 c Business and Professions Code)or that he is exempt therefrom and GTY inti. 1. )'PLUMBING PERMIT Txl o- q�
M H the basis for alleged exemption.Any violation of Section 7031.5 oc1i yy •y'� w^f' STORIES TYPE CONSTR.
re
c by any applicant for ne subjects the applicant to a Civil penally ALTER-DRAIN -WATER (EA.) 4.00
of not mothan five dollars(55001.):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation.will do the work,and the stmc(am is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00 '
Code:The Contractors License Law does not apply to an owner of
properly who builds or improves thereon,and who dues such work FIXTURES,PER TRAP 4.00 SC.FT.FLOOR AREA TOTAL ACREAGE
menta re of rote his own employees,provided that such improve-
mentsare through
or offered employees,
or Sale.If, that such
building GAS-EA.SYSTEM-1INC.4OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- . - RES NO CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 ES ❑ ❑ ❑ ❑
❑ 1,as owner of 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 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 6 (EA.) 1.00
contracts for such projects with a contractuds)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO. PARCEL NO.
❑ tam exempt under Sec. .B.&RC.for this
reason WATER HEATER W/VENT 4.00 /,003
Dale Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that 1 have a certificate ofconcent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
_ copy the o e .3800,Lab.C.l.
alicy N o pony
O ❑ Certified Copy l; Rb mlSh FIRE$PRINK ENERGY T-24
Z 2 Certified y Is f wish th 'ity inspection division.
HO A plicanl MISC.- REFER TO ORD. Y❑ N[] Y ❑ No
jr H CERTIFICATE OF EXEMPTIO 'ROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG, Q. (J(/ Y❑ N[3 Y❑ NE]
(This section need not be completed if the permit is for one TOTAL
hundred dollars IS 100)or less.) ,'•.''. - - - r
o-.
V O I certify that in the performance of the work for which this per- '•(' ' 1, .� 'r. "T'7YLj'-FEE SUMMAR Vj 4'^U. F mit is issued,I shall not employ any person in any manner so as to GTY. ,MECHANICAL,PERMIT:,'i ;s' •FEE;
U become subject to the Workeri Compensation Laweof Cxlifarma. '0
Is. Date Applicant ALTER OR ADD TO MECH. ^ 4.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F ? emption,you should become subject to the Workers'Compensatum APPLIANCE 4.00 PLAN CHECK 7 `
provisions of the Labor Code, you must forthwith comply with FEE a( J IvO�
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10pODC.FAU 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 C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.P.50
Lender's Addr4ss ELECTRIC
I certify that I have read this plication and slate that the above VENTILATION FAN (SINGLE) 3.00
information n correct I agree to comply with all oily and county PLUMBING /Q, (�
ordinances end slate laws relating to building l city and°n, and 130ILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00
hereby authorize representatives of (his city to enter upon the BOI LER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.• REFER TO ORD.
Cupertino against liabl"ties,judgments,casts and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
May in any way ac a against said City in consequence of the
granting of Is pcVy. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL`.•x. ff S.
Signature of pplicant/Co I Date a•.
OFFICE COPY