6133`-'APPLICAinTO FILL IIN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT lDENTIFICATION
APPLICATION & PERMIT
BUILDING- ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
6133
AGss
EVCDDO O=N
OOWN
WNERS �/EALy
,mow-c,411ihl Ave . PHONE 73`-:
.
QTYELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
CONTRACTORS
NAME
W IN OW 'k RC rQtJ S. LHC LIC. NO. so 7
UTLETS- SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
CONTRA
ARESS Rs
DD
CON
PPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
510 o i PHONE _
DATE OF APPLICATION
ARCHITECT
ENGINEEF Mo NO.
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH, ss ENG,
CIRCUIT 5.0D
PERMIT
PERMIT VALIDATION
rrEMP. METER OR POLE INS.._ 15.00
S A ZIv
i
APPLICANTS
DDRESMOTORS
SEE FEE SCH.
SERVICE CHANGE 10.00
,/[��O 3
L ICI7N S E D CONTRACTO RS DECLA RATION
I hereby ul firm that I am licensed under provisions of Chapter 9
(conrmeneing with Section 7000) of Division T of the Business and
Professions Cut! {pit my IiCen c is in full force and effect.
License Class -"14 LIC. Number Cl Cw_9-G�A
Dulu_i t� p�G ConiruclorVqTN_DVV7;TC-0-
J_ OWNER -BUILDER DE
that I on exempt from the Contramo Ir License
1 hereby at following
Law fornycitllowtnunty hihrequi L5.Businessand Professions
Code: Anymolish (if county any requiresu permiuoconsuance, also
improve, demolish, or repair any 'vadum, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
I.aw(Chapter9(commencing with Section 7000) of Division 3 of the
Itusiness and Professions Code) or that he is exempt therefrom and
ISSUANCE DATE
BLDG.
❑
ELECT.
PLG. MECH.
❑
BUILDING PERMIT
INFORMATION
MISC. - REFER TO ORD y
PERMIT ISSUANCE 6.00
VALUAn ON
�� 000- ,
�
S/FT.
ELEC. CONTR. LIG N0.
ELEC. �
TOTAL
PERMIT TO .y✓
QTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects Ilse applicant to a civil penalty
of not more than five hundred dollars ($500).).
�
ALTER -DRAIN St VENT -WATER (EA.) 4.00
❑ I, as owner of the properly, or my em8loyecs with wages as
du it sole compensation, mpesation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 2.00
occ GROUP
NL'
RES VWT TS S/0T
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law dos not apply to an owner of
'/j
/j
/f'
FIXTURES - PER TRAP 4.00
$0. FT. FLOOR AREA
0/000
TOT q ACREAGE
"
properly who builds or improves thereon, and who does such work
himself or through his non employees, provided that such improst-
ments are not intended oroffered forsals. ILlbo,ver, thebuilding
GAS - EA. SYSTEM -1INC. 4 OUTLETS 4.00
orimprovement is sold within one year of completion, the owner-
hoilder will Imve the burden of proving that he did net build or in-
Prove r t purpose of sale.).
❑ 1, as owner of the properly, am exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 1.00
BUILDING USE
R IND co Pa other
�.
INDUSTRIAL WASTE INTER. 20.00
licensed contractors to construct if,, project (Sec. 7044, Business
anJProfessions Code I'lie Contractor's License Law docs not apply
to an owner of property who builds or improves thereon, and who
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSOWMRCELNO.
S -7-17-0.1,e
contracts for such projects with u contractor(s) licensed pursuant to
the Contractor's license Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ l am exempt under Sec.-. BAP,C for this
reason
WATER HEATER W/VENT 4.00
Owner We
WATER SYSTEM 4.00
ACG DATE
ACG FILE NO.,
WATER TREATING EQUIP. 4.00
WORK ERS'COMPENSATION DECLARATION
I hereby alfrm that l have a certificate of consent In sel4lnsurt'
Ta, a certificate of Workers' Compensation Insurance, or a cert i ficd
'+
ZONING
ENG. SITE NO.
_
T
^ ��
copy thereoffSec. 3900, Lab,C. I
Policy Nn. Co;i r.,
,
FIRE SPRINK
Y NE]
ENERGY T-ZE
Y El NO
O Certifi opy"Ince y'lu hshedut�gQt �3 ���
)Q C � ix le itIf the ty in, , I n dhvRlo .
Appliuwl
-1
MISC. - REFER TO ORD.
C1,7, ION FROM WORKFKS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
ALU.C.
PLO. CONTR. LIC. NO.PLG.
TOTAL
COMPENSATION INSURANCE
('f his section need not be completed if the permit is for one
Y� rv�
Y� N�
hundred dollars IS 100) or less.)
I certify tont in the performance of tire work for which this per-
mit is issued, I shall not employ any person in any manner so as to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
�3 Uel. 2NOTICE
become subject to the Workers' Compensation Laws of California
Dat, -Applicant
. .
ALTER OR ADD TO MECH400
'1'O APPLICANT- If, after making this Certificate of Ex-
APPLIANCE 4.00
PLAN CHECK
emption, you should home subject t0 the Workers' Compensation
provisions of the Labor Code, you insist forthwith comply with
such provisions or this permit shall be deemed! revoked
AIR HANDLING UNIT (TO 10=C.F.M-) 3.00
FEE
AIRHANDLING UNIT(OVER M000C.EM.)5.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
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 (See.
3097,Civ.C),
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's aNme'
ILeeds,',...c
E
H EATI NG UN IT (OV R 100,000 B.T.U.)7.50
ELECTRIC
I Left it'y that I have read t his applicat ion and state that the above
VENTILATION FAN (SINGLE) 3.00
infonnalion is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
-
BOILER -COW (3 H.P. Or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100,000 RTUI SEE FEE SCH.
MECHANICAL
Hereby authorize representatives of this city to enter upon the
abovcn.cntum,d property for inspection purposes.
0Ve) agree to Save, Inde nify and keep harmless the City of
MISC. - REFER TO ORD.
Cupertio ain't liahi 'ties udgm:n1,, cods and expenses which
may s y ac a ainst said City in consequence of the
CONST. TAX
PERMIT ISSUANCE 3.00
ob go t 1 -
3 _ / 7 _ g 5
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
/ 3.? / -�
Si ufe of Ap is t/Contractor Date
INSPECTOR COPY