6927 I _
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
" , BUI'LDINGP OJECT ID NTI FICATION - PERMIT NUMBER
aDILDING �, , APPLICATION & PERMIT 6927^n
AUDRESS
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 9 G r
OWNEus77 / 1 PLAN CHECK VALIDATION
Y?
NAME Uj�icTjNU /�wN�CruTE� OTELECTRIC PERMIT "' FEE
PHONE
CONTRACTORS UTLETS .SWITCHES.RECEP 5.00/1.00
NAME
Lc.ry `- LIGHTING FIXTURES 5.00/1.00
ADDRESS APPLIANCES DPPLIANCES-RESIDENTIAL 4.00
CONTRA
P NEQ PANELS 5.00 DATE OF APPLICATION
ARCHITECTSIGNS 6.DD PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. ISIGNS TRANS. 3.00
ARCH.OR ENG, ISPECIALCIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 15.00
APPLICANT'SJ
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
DO .o LICENSED CONTRACTORS DECLARATION
rt v u 1 hefe by affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y< y (commencing with Section 7000)of Division 3 Of the Business anJ BLDG. ELECT. PLG. MECH.
y z I'mfess�ns Coyle,and my license is in full force and elle I. _ ❑ ❑ ❑ 2
License Class Lic.Nombe _ O j.�
OF z ° Uwe_ Z-/_ Canino., S-SNE�J'
OF
x s BUILDING PERMIT.
rc ¢ w a OWNER-BUILDER DECLARATION INFORMATION
w3 w r 1 hemby affirm that I am exempt from the Contractor's License MISC..- REFER TO ORD
LOQ Law for the followingreason.(Sec.7031.5.Business and Professions pERMIT ISSUANCE VALUATION S/FT.
- Code:An cit count whichne 6.00
ANY y or y yaitore Permit 1.[OnPD¢Lrleq ELEC.CONTR. LIC.NO.
ar ¢ improve,demolish,or repair any structure,prior to it,issuance,also EIEC.
D tt requires the applicant for such pe,ndt to file o signed Gale ical that TOTAL Pggtd'S TO
A w m" he is licensed pursuant to Ilse provisions of the Contractor's License M
H z i I.aw(Chapter 9(Commencing with Section 7000)of Division 3 oflhe
- - a Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢ f Oo the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
;m by any applicant for a permit subjects the applicant o a civilpenalty gLTER-DRAIN -WATER (EA.) 4.00
of nal more than five hund,rd dollars($500).):
❑ 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
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Coda The Contractor's License Law does not apply to an owner of
polperty who builds or improves thereon,and who dries such work FIXTURES-PER TRAP 4.06 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees.Provided that such improve.
mentsare not intended or offered for sale.If.however,lire building GAS-EA.SVSTEM-1 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-
proveforpurposeafmlc0 El
❑ El 1:1❑). INDUSTRIAL WASTE INTER. 20.00 ANO PB omer
❑ L as owner of the property,am exclusively contracting with
licensed contractors to construct the project ISec.7044,Business LAWN SPRINKLERS-I INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:'I'he Contractor's License Law docs 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 contructodsl licensed pursuant to
lire Contrlaor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ Iran,accept under sec ,H.&P.C.for Ibis WATER HEATER W/VENT 4.00
reason
OWner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
- WORK Ii RS'COM PENSA'I[ON DECLARATION WATER TREATING EQUIP. 4.00
I hereby atirt that I have a ccrtificwe ofconsent In self-insure. ZONING ENG,SITE NO.
or a c_vitilie,de of Wo,kcrs'Compensation Insurance,or a certified
copy IheJ��Lf fSee 38 .Lab.C.l.p�.�.
I'olicY41M' ��mp:Illy c/u/rri-�"u
O ❑ Certified copy is hereby famished. FIRE SPRINK ENERGY T 24
Z Z ❑ Cedil' I rpY is f�I with Ia cit impcc,lion division. MISC.- REFER TO ORD. v N v N
O Applicant- copy is - ❑ ❑ ❑ ❑
CCN CERTIFICATE 017 EXEMPT( NpROM WORKERS' PERMIT ISSUANCE 6.00 FLOODZONE A.L.U.O.
UJ >_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLO.
d O 1'I'his section need not be completed if the permit is for one TOTAL Y❑ N❑ v❑ N❑
2 hundred dollars IN 100)or ICu.I
U O 1 ccrlify that in the performance of lire work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any manner so as to
OL) becmncsubject to The Workers*Compensation Laws of California.
uatc Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} vii NOTICE '10 APPLICANT: If,after making this Certificate of F.x-
r 2 cmpli in,you should become Subject to the Workers Cnnipeasatio r APPLIANCE r t.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 10,000QF.M.)' 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OV 'F,No . SEISMIC FEE
1 hereby uflinn that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00 /61
the performance of the work bar which this permit is issued(See. HEATING UNIT IT
100,000 B.T.U.) 4.00 MICROFILM
3097,Cis,C.l.
Lender's Name H EATING UN IT(OVER 100,000 B.T.U.17.50
Lender's Address ELECTRIC
I ccrlify that 1 have read this application and sure mat the above VENTILATION FAN (SINGLE) 3.00 Q
.
information n correct.1 agree to comply with rl city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construction,and �
hereby authorise representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL ---
above-mentioned property for inspection purposes.
(WC) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses whichpERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence of the
gran ti flhis permit. ,` MECH.CONT. LIG NO. MECH.
'� 2 f��f7
TOTAL 1/c p9 TOTAL
Slgreu Apphca�/Co�r7 Uate
/
OFFICE COPY