4897 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
13U LDI NO PROJECT I DENTI FICATI ON PERMIT NUMBER
aUILGING APPLICATION & PERMIT 4897
apORE39 �� �
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNERS
�l PLAN CHECK VALIDATION
NAME
� ..FF����q 1*�S. �/� A�sE PITY. . ELECTRIC PERMIT �`'T FEE' 4 �
14NSNB PHONEJG'J•JJCV -
CONTRACTOR'S
NAME Qj'1 OUTLETS-SWITCHES-RECFP 5.00/1.00 _
1HIS 0- k• Sac.No. LIGHTING FIXTURES 5.00/1.00
f.0ACRIESS CRs era APPLIANCES-RESIDENTIAL 4.00
�t OESS �y Ep�.,���`��a �a�F/
1�9 �• ovp%j Fh5Pg 1FI`ANE IJV_(OId PANELS 5.00 DATE OF APPLICATION
ARCHITECT / O1 SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR �a,s
ENGINEER If�sJK Neg• G •1$2
LIC.NC �j SIGNS TRANS. .00
.
PAI
ARCH.OR ENG' SPECIAL CIRCUIT ,00 PERMITVIMAJID
ADDRESS
Oc %j awto. "OdWA ZIP TEMP.METER OR POLE I S s 1
APPLICANT MOTORS 1984
ADDRESS LICA
r-39 s, Fs�
9 WOsq.1. VF . SERVICE CHANGE Qmi ,�-•/'no
o o LICENSED CONTRACTORS DECLARATION (!�"(.,P"'•I
< v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w < $ fcommencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
Professions Cod nd my license is in full force'a effe t. ❑ 10 El 11z O w LicenseC ss LiC.Number
o F Dem Contractor
P L L W+ SUILOING PERMIT
¢ ¢W a OWNER-BUILDER DECLARATION -INFORMATION
wo a u MISC.- REFER TO ORD
; H 1 hereby affirm that I am exempt from the metra d Pr License
u0¢ Law for the following reason.(Sec.7031.3,Busineisand Professions VALUATION E)FT.
H _ PERMIT ISSUANCE 6.00 os
Code:Any citymol or county which structur a permit to construct.alter,
¢ ¢ ¢ o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC. 0�a
C M requires the applicant for such permit to file a signed statement that TOTAL/W PERMIT 0
a $ he is licensed pursuant to the provisions of the Contractor's License /
F z i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe - 1/
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT., FEE
i i o
¢ H � the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(5500).1:
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP REE.UNITE
their sole compensation,will do the work,and the structure is not
intended or offered for Sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does Such work FIXTURES-PER TRAP 4.00 SO.FT,FLOOR AREA TOTALACREAGE
himself or throughte his own employees.Provided that such improve-
ments
mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 IINC.4OUTLETS 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 build or im- RES IND CON PB Orne.
prove for purpose ofsaleJ. INDUSTRIAL WASTE INTER. 20.00 1:1 ❑ El E] 13❑ 1,as owner of the property 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 5(EA.) 1.00
contracts for such projects with a conlractons)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Dale Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE N0,
WORK F.RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hemby affirm that I have a certificate ofconsent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers Con ration Insurance,or a certified
copy there o ISec.3800,Lab.C.).�P1 f, =p
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T24
Z Z ❑ Certified ay is fide tphe city inspection division. MISC.- REFER TO ORD. V N V N
Applicant L1a1J ❑ ❑ ❑ ❑
CC rn CERTIFICATEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A,L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.No. PLG.
CL O (This section need not be completed if the permit is for one TOTAL V❑ N❑ v ❑ N❑
D Z hundred dollars(S 100)or less.)
U O 1 certify(hal in the performance of the work for which this per, CITY MECHANICAL PERMIT _ FEE FEE SUMMARY
LL mil is issued,1 shall not employ any person in any manner to
so as
U become subject to the Workers'Compensation Laws of California.
W Datt Appllcanl ALTER OR ADD TO MECH. ' 4.00 BUILDING s,00
} w NOTICE TO APPLICANT: If,after making this Certificate of Ex-
FZ emption.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(TO 10p000.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10.00OC.F.M.) 5.00 SEISMIC FEE y�
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 ISec. MICROFILM
3097,Civ.C.1. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lenders Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC ��0
Lender's Address
• 1 certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.or100,000B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP IDver 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 liabilities,judgments, Costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence of the
granting of this perm,.I. MECH.CONT. LIC.NO. MECH. (' O
_ TOTAL TOTAL- �S
are of Applicant/Contract Date
OFFICE COPY