5651 APPLICANT TO FILL IN INFORMATION WITHIN.RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT 5651
AUDDRLSs
/Q •tZ v� .Q��I L�,�-.� ' BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'�yn•J^A QQ.4 t"/-`•'' •TI9JN C4NTL�C- i. PLAN CHECK VALIDATION
Name OTY. ELECTRIC PERMIT FEE
n NET
co rRAGTGRs
NAME UTLETS-SWITCHES-RECEP 5.00/1.00
LIC.No. LIGHTING FIXTURES 5.00/1.00
ApR,SCTOR's
DPPLIANCES-RESIDENTIAL 4.00
CONTRA
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS B PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. -7 Q �' dLAw` ED� � SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS Wim'/{O V�Y�
f1N TEMP.METER OR POLE INS. 15.00
APPLICANTS (+ !''$'1 X41. MOTORS SEE FEE SCH. J
ADDRESS 137 (]. t
0g7 SERVICE CHANGE 1EORD
woo LICENSED CONTRACTORS DECLARATION'
< v U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE _
yah Icommenchrg wdh Stt(ion 70001 of Division 3 of the Business anJ BLDG. ELECT. PLG. MECH.
H H z Professions Code,and my license is in full force and effect. ❑ ❑ ❑
z o H - License Class Lic.Number
0 z w Date-Contractor
a x E BUILDING PERMIT aM c
m a, w ¢ OWNER-BUILDER DECLARATION INFORMATION`' " - f
w LL I- I hereby affvm that I am exempt from the Contractor's License
MISC.- REFER TO o¢ Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE VALUATION S/FT.
.
Code:Any city or county which requires a permit to construct,alter, A
Q � ¢ 0 improve,demolish,or repair any structure,priorto its issuance,also ELEO.CONTR. LIC.NO, ELEC. 431,000
O I, requires the applicant for such permit to file a signed statement that TOTAL /L'D PERMIT TO
u w m u A
he is licensed pursuant to the provisions of the Contractor's License
I- z > Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe Condos. (8 units)
4 D Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ H the basis for the alleged exemption.Any violation of Section 7031.5 OT(g®A TYPE CONSTR.
to F, by any applicant for a permit subjects the applicant toa civil Penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00 IJOY
of not more than five hundred dollars($500).): 2 5 N. Hr.
❑ I,as owner,.1 the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 P RES.UNITS
their sole compensation,will do the work,and the structure is not of apuf hQ
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 R-1 8
t
Code:The Contractor's License Law does noapply to an owner of
property who builds or improves thereon, of who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not mounted or offered for sale.If,however,the building GAS-EA.SYSTEM-1 1NC.4 0UTLETS 4.00 14,000
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4(EA.) 100 BUILDING USE
builder will have(h
e burden of proving that h . . .
e did not build or im" REB IND CON PB ower
P or Pn,PR,uf,.I,.). INDUSTRIALWASTE INTER. 20.00
1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
li Lased contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Proessiens Code'.'I'he Contractors License Law does not apply
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 269-2-2- /
contracts for such projects with a contractors)licenced pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NNo. PARCELNO.
the Contractors License Law, /
❑ lam exmnpt under See ,B.&I'.C.for this WATER HEATER W/VENT 4.00 7575 1l/JI
mason
Owner Datee'r WATER SYSTEM .4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of enesent to self-mone. ZOrvING
Far u certllnoate of Workers'Compensation InRlmnco,or a Certified n ENG.SITE NO.
copy Ihereot(Sec.3800.Lub.C.). U Al 14_
Policy No. Company -
0 ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T-24
Z Z o Certified copy , filed with the city Inspection division. MISC.- 'REFER TO ORD.
O Applicant Y ❑ N❑ Y ❑ N❑
� y C1i R'nFICA'I E 01'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.UC.
LU > COMPENSATION INSURANCE: PLG.CONTR. LIC.NO. PLG.
d O (This section need not be completed if the permit is for one TOTAL YE] N❑ Y❑ N❑
Z hundred dollars(S 1001 or Iess.)
U O 1 certify that in the perfornn:mee of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL P mit is issued,I shall not employ any person in any manner so as to
O U bee uhje to the Workers' om pensation Laws of California.
BUILDING
Es. Far- . I Applicant ALTER OR ADD TO MECH. 4.00 1,260.50
} rn No .E'I' ArPPLICANT: If,alto making this Certificate of Es-
Z emption,you should become subject to the Workers'Compensution 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 10AOOC.F.M.) 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER IO,OODC.F.M.) 5.00 SEISMIC FEE 30.17
I hereby uffirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
DIC performun cehich the work for wthis permit is issued(Sec. MICROFILM
3097,Civ.C.). r HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name A�� /`i-I'4G_ HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lo nderti Ad that
hs'�hS- etha Q. bo ELECTRIC
sc-
I certify that 1 have read this o application and slate that the above VENTILATION FAN (SINGLE) 3.00
information n correct,1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B-T.U.) 4.00
hereby authorize representatives of this city to outer upon the BOILER-COMP lover 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, c Sts and expenses which CONST.TAX
may in any way acem a..' t S. C' in consequ ace of the PERMIT ISSUANCE 3.00
n us penal MECH.CONT. LIC.NO. MECH.
��//Zy . TOTAL TOTAL 1,290.67
Signature of Applicant Contractor ate ,r O
OFFICECOPV /