2166 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL. POINT PEN ONLY
7T NNBER
BUILDING PROJECT IDENTIFICATION t�l�IM216 6
BUILDING APPLICATION & PERMIT �
ADDRESS
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
PLAN CHECK VALIDATION
Cyis�9�=.�2a9 L
'.ELECTRIC PERMIT- FEE
PHONE . . .•• q '
CONTRACTOR'S S-SWITCHES-RECEP 5.00/1.00NAME
LICNo. G FIXTURES 5.00I1.00
roNTRAcrons
�¢ PPL(ANCES-RESIDENTIAL 4.00
ADOREss_
(Ln PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT 6.00 PLAN CHECK FEE C.NO.
OR SIGNS
ENGINEER LIC, 3 DD
LIC,No. SIGNS TRANS.
ARC GR ENG. SPECIAL CI RCU IT 5.0D PERMIT VALIDATION
ADDRESS
zlv EMP. METER OR POLE INS.. , 15.00
APPLICANT'g
AOORESS MOTORS SEE FEE SCH. /
M„�/�
'Z (ly SERVICE CHANGE 10.00 V
Woo LICENSED CONTRACTORS DECLAR TION
<v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
M,a ww (coencing with Section 7000)of Division 3 of the Bmmessand BLDG. ELECT.. PLG. MECH.
M, 0 imm
Professions Code,and my license is in full force and effect. ❑ ❑ El [3
O ffi License Class Lie.Number
4 z w Date Contractor
a x f '-'�*BUII:OING PERMIT k°'U
¢ ¢W OWNER-BUILDER DECLARATION C,,*rg vNF-ORMATION ;,J.
u`xI;LL rA I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD °vs
Y P VALUATION S/FT.
Fa.04 Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 6.00 O!
Code:Any city or county which requires a permit to construct,alter, �-.BCJ
a ¢ a improve,demolish.or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. // QI
p LL requires the applicant for such permit to file a signed statement that TOTAL �� ,• EIyy2
w8 w he is licensed pursuant to the provisions of the Contractors License _ s u • �JjeJ iF
> Law(Cha ter 9(commencin with Section 7000)of Division 3 afthe L:•- i * + a 'x " 71sT-"
i o Business and Professions Code)c:that he isexempl there(ram and GTY. > e PLUMBING PERMITj -ifao+l +FEE
¢ r S the basis for the alleged exemption.Any violation o(Section 7031.5 s,,' .: = .v«.'.?.„^,.e Y.. .e .- �, �a! a.. "A f . 1'+. STORIES ;0*,T
i g by any applicant for a permit subjects the applicant to a civil penalty T s�
.fact more than five hundred dollars 15500).1: ALTER-DRAIN (EA.)
17( I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2,00 DLC.GROUv RES.UNI
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
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who dues such work FIXTUR ES- TRAP 4.00 SQ FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such improve- GAS
meats are not intended oroffered forsale.If.however,the building -EA.SVS M OUTLETS 4.00 •Jp
or improvement is sold within one year of completion,the owner- GAS-EA.S •OV 1.00 BUILDING USE
builder will have the burden.f proving that he did not build or im- RES IND CON Pa Omer
prove for purpose of sale.). INDUSTRIAL S TER. 20,00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business ILAWN SPRINKLERS- I ,B- 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves(hereon.and who LAWN SPR IN •OVER WEA.) 1.00
contracts farsuch projects with a commcmrls)licensed pursuant to SEWER-SANITAR - RM EA.200ft/8.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ I am exempt under Sec. .B.&P. .for this WATER AN
W/VENT 4.00 ^ -�
rea on
K qest, WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COM1IPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified =NIryG ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.). /
Policy No. Company
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z 2 ❑ Certified copy is filed with the city inspection division. MISC.• REFER TO ORD.
O Applicant - Y❑ Y NEI
- PERMIT ISSUANCE 6.00 --�
- CERTIFICATE OF EXEMPTION FROM WORKERS' FLOOD zoNEW"ll-rti
UJ > COMPENSATION INSURANCE PLG CONTR. uc NO PLG Oa ❑ .._o-I�_
1 O Y(This section need not be completed if the permit is for one TOTAL SCJ �O'
2 hundred dollars IS 100)or less) ;+ " 1'A7-`e._ q
U O 1 certify that in the performance of the work for which thisper SU ARV OTY LL b- mit is issued,1 shall not employ any person in any manner so as to !,� , � ... , x., =,. r: a .4fy
L0 w become subject to the Workem'Compensation Laws of California. BUILDINGDam Applicant ALTER OR ADD TO MECH. 4.00NOTICE TO APPLICANT: If,after making this Certificate of Ex-
emp!ion,you should become subject to the WorkeriCompensation 1 APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10.0MC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10)30DC.F.M.) 5.00SEISMIC FEE
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(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lenders Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that l have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00 d 00
information n correct I agree to comply with all city and county PLUMBING .moi
.rdinancesformatio and state laws relating to building constall
ands, my BOILEfl-COMP(3 H.P.Or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEESCH. MECHANICAL /
t above-mentioned property for inepsclion purposes.
(We) agree to save. Indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses whichPERMIT ISSUANCE 300 as'/ CONST.TAX
Troy in any way accrue against said I .
in consequence of the r--
ng of this per MECH.CONT. LIC.NO. MECH. <'.M1!'+"-' .""'•'* :
TOTAL
'nature of Applicant/Contractor Date
OFFICE COPY