6276 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDI NG PROJECT I DENT]FICATI ON PERMIT NUMBER
IWILOWG APPLICATION & PERMIT
ADDRESS BUILDING - ELECTRICAL-PLUMBING-MECHANICAL ' 6276,
-n 1 Z ig ,, O`.60 ✓
NEa , yp I,\ PLAN CHECK VALIDATION
AM
ELECTRIORERMITs j.4"'*`n;� 1 J'111FEE�*
1411 B'+4--c-.- 497
NAMERacroRs OUTLETS=SWITCHES-RECEP _ 5.00/1.00
( a-e- J LIC,NO,'$7q`Q3 LIGHTING FIXTURES 5.00/1.00
CCONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ONTRAS QJ'C�.as+F L4/5
( PANELS' - 5.00 "DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
" ENGINEER
Llc.No. SIGNS TRANS. 3.00
ADDRESS era. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP ITEMP.METER OR POLE INS. 15.00 lal
APPLICANTS
aooREss MOTORS SEE FEE SCH. D
SERVICE CHANGE 10.00
00 LICENSED CONI'RACI'ORS DECLARATION J.
a u U I hereby affirm tlwl 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
N rt h (commencing with Section 7000)of,Division 3 of the Business and - BLDG, ELECT. PLG. MECH.
y z Professions Code m 1 license is in full I'oreg,. it fl'ec
2 i w w License Class=Liu.Numbe sr 6 '1 �.' ( ❑ ❑. ❑
m H Ilene-s Contractor_ _
m - . BUILDINO'P.ERMIT -
rc w OWNER-BUILDER DECLARATION i.r
w0 LL N I Hereby al firm that I air exempt from the Contracto'r's License MISC.- REFER TO ORD .".'INFOHMATiION,
Fu. O4 Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE VALUATION E/FT.
SDw Code:Any city or county which requiresapermit to construct.oiler, 6.00
d- M QG IIIIprove.demolish,or repair any structure,prior t0IIS IS$nJMe,8Sn ELEC.CONTR. LIGN0. ELEC.
oe requires the applicant for such permit to file u signed statement that TOTAL
w m m he is licensed pursuant to the provisions of lire Contractors License PERMIT TO
Fz >
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
3 4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMITy*'FEE'-•.,
R F o the basis for the alleged exemption.Any violation of Section 7031.5 .'." ?�•;'�'. '. ,STORIES I TYPE CONSTR.
n ; m by any applicantfor a permit subjects the applicant to a civil Pollahy '
of not prore than five hundred dollars(5500).): ALTER-DRAIN&VENT-WATER (EA.) 4.00
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC,CROUP RES.UNITS
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
propertywhobuilds or improves thereon,and who does such work F IXTUR ES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ownsare not intended or offered for sale.I f,however,the building GAS-EA.SYSTEM-,I INC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BURDING USE
builder will have the burden of proving that he did not build or im- ES IND CON PB Omer
prove for purpose ofvleJ. - INDUSTRIAL WASTE INTER. 20.00
❑ 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 Cmic:'I'he Contractor's License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) , 1,00
confacls for such projects with a contractions)licensed pursuant to
the Contractor's License law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
7r ❑ lam exempt under Sea ,B.&1'.C.lim Ibisle.o
on WATER HEATER W/VENT 4.00
Owncr 'Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSA"PION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
Cop Its Lob.C.)./�
Pol,KA3,)-2}l & any_FG_4
O CI Celrilisd copy is hereby F Fished FIRE SPRINK ENERGYT]4
Z Z W Certified c'oov Wiled with the city inspection division. .
O Applicant__ MISC. REFER TO ORD. Y❑ N❑ Y ❑ No
Ln CERTIFICATE 017 EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU > 'COMP(?NSA'I'ION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This action need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
D Z hundred dollars IS 100)or Iem,)
U O I certify Thm at the performance of the work for which this I, ^`I' ' . FEE SUMMARY
OTY�yi,. *'^, m:N1ECHANICA'L'PrERMITw} „x- a i
,�tr.xr
LL F- unit Is issued,I shall not employ any person in any man net so as to yo-S.S' P
O ED become subject to the Workers'Compensation Laws of California. `
a DaI° Applicant- ALTER OR ADD TO MECH. 4.00 BUILDING'
} H NOTICE TO APPLICANT: If,after making this Certificate of H.-
h ? eniption,you should become subject to Om 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 10=C.F.NKU 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
1 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 IO VER,100,000 B.T.U.)7.50
'lender's Address ELECTRIC
I certify flint l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct.I agree to comply with all city and county PLUMBING
ordinances and state laws relating m building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.)•4.00
hereby authorise repersenottwes of this city to enter upon the BOILER-COMP(Over 100,000 BTU(SEE FEE SCH.
above-mentioned property for inspection purposes. MECHANICAL
(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 Citym
in nsequce"of the
grunting of ti's per MECH.CONT. LIQNO. MECH.
e
TOTAL TOTAL'
Signatureof Applicant/Cotracmr Date -
OFFICE COPY