6945 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTI.F I CATION PERMIT NUMBER
DLDING20ST APPLICATION & PERMIT
ADDRESS -3 ✓tau BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
6945
45
C��r
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
. ` �. PHONE
co TRAcraR'
NAME 4A_ UTLETS-SWITCHES-RECEP 5.00/1.00
�. p_Qw\ LIC.No. ll LIGHTING FIXTURES 5.00/1.00
C,ONTRACTOR'SPPLIANCES-RESIDENTIAL 4.00
ADDRESS ( (�
oe -EfvHONE O -1 PANELS 5.00 DATE OF APPLICATION
ARCHITECTSIGNS - 6.00 PLAN CHECK FEE P.C.NO.
OR ,
ENGINEER
1.4 A io� LIC.NO. SIGNS TRANS. 3.00 '
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS pe - SPECIALCIRCUIT 5.00
Q ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS
ADDRESS MOTORS SEE FEE SCH.
A
SERVICE CHANGE 10.00 p
o02 • ' ///p s'
Foo LICENSED CON'I'RACiORS DECLARATION -
u u I hereby affirm that 1 ton licensed under provisions of Chapter 9 11 ISSUANCE DATE
z (cnnunenping with Section 7000)of Division 3 of the Rit,mess and
¢a BLDG. ELECT, I PLG. MECH.
F H i I'ro fcssions Coslc 1 try licwac is in full fonf•'�'{�{�( El ❑ Elyy.��JJt -1�-J=fi
z O w License Clnss-�.p._Lic.Number
O r o 1)me Contractor_eA
a E BUILDING PERMIT
y¢ Q w ¢ OWNIi R-BUILDER DECLARATION INFORMATION
oaea MISC.- REFER TO ORD
X
g w H I hereby affirm that I arm exempt from the Contractor's License VALUATION $/FT.
or v, Law for the following reason.ISec.7031.5.Businessund Professions PERMIT ISSUANCE 6.00
fw0E Code:Any cilyorcounty which requires a permit to const R¢t,alter, ]�� oo�
Ec Q ¢ improve.demrlhSh,lir repair any structure,prior to Its issuance,also ELEC.CONTR. LIC.NO. ELEC. of
tu
K O u requires the applicant for such permit to file a signed stalennenl that TOTAL PERMIT TO
a wAs m he is licensed pursuant to the provisions of the Cent Nie or's License
F Z r
Law(Chapter 9(cnmmencing with Section 7000)of Division 3 ofthe
_ ¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE <--,w C'
_ ¢ F O the basis for the alleged exennption.Any violation nf$eetion 7031.5 STORIES TYPE CONSTR.
n 3 $ by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars(S500L): 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.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not - t
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 `
Code:The Contractor's License Law docs 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 TOTAL ACREAGE
• himself or through his own ennployces,provided that suchinnprove-
Rentsurc net intended or uttered brsale.If,however,tlrebuih ing GAS-EA-SYSTEM-1 INC.40UTLETS 4.00
or innprovement is uld•within-one-yem of con.fiction,fit,owner- z
bei Wer will have the burden of proving that he did nil build or inn- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
prove for purpose of salt.). INDUSTRIAL WASTE INTER. 20-00 RES IND CON Pe Omer
13 L as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensedcontractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:'1'he 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 contmdorts)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEICIN r
❑ I am exempt under Sec.-,L&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.,DATE ACC.FILE NO.
WORKERS'(OMPENSAT ION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate Ofconsent to sel Finsure, ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
." copy thereof(Sec.3800,Lab C.).
Policy No. CmnpanyylQ IG
O ❑ Certified copy i5 hereby furnished. FIRE SPRINK ENERGY T 24
Z z V[CerliOed copy is files{, ith the city inspection division. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
0 Ap61'cant v N v N
y CERI'WICA'Ili Ons EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR.' LIC.NO. PLG.
0- 0 1'1'his section need not be completed if the permit is for one TOTAL Y ElN❑ y E] N[:J
hundred dill...(S 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not CnlPloy any person in any manner m as to
O L)become subject to the Workers Compersation Laws of California. p dL
a Dale ApplicantALTER OR ADD TO MECH4.00 BUILDING
>_ In NOTICE TO APPLICAN E: If,after making this Certificate of nix- . 4
F.. ?
eruption,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 per...it shall be deemed revoked. AIR HANDLING UNIT(TO 10MEF.M.) 3.00
i�
CONS'IRl1CI'ION LIiNDING AGIiNCY AIR HANDLING UNIT(OVER 10070EEM.) 5.00 SEISMIC FEE 4- 70
'
I hereby,affirm that there is a comarection lending agency No EXHAUST HOOD (WITH DUCT) 2.00 P
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Cie.C.). HEATING UNIT(TO 100,000 B.T.U.) 4-00
Lender's Add A
e�� HEAT[NG UNIT(OV ER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that 1 have read this application and stale 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-OOMP(3H.P.or100,000B.T.U.) 4.00
hereby authorise representatives of this city to enter upon the BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL
.hove-mentioned property for inspection purposes.
(We) agree to save, indemnify and keepImrmless 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 gggggg- rue against said City in consequence of the
granting of this prfmil. MECH.CONT. LIC.NO! MECH.
[7 -I -t _�� TOTAL TOTAL ��� 9c
Sigllatore of Appikai Conlmctor U.7
INSPECTOR COPY