6978 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDINGc; L7 APPLICATION & PERMIT
,
ADDRESS ��/ '�f/� _
/C37/ 7"/F J9/ l%/ �S/Q BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 6978
OWNER'S PLAN CHECK VALIDATION
NAME OTV. ELECTRIC PERMIT- FEE
f r S PHONE n' -5/-/L,G^^
CONTRACTOR'S
P/
ME . /� / OUTLETS-SWITCHES-RECEP 5.001.00
Pr�/rY0 Yl a' LIC.NO ,� /fLY LIGHTING FIXTURES 5.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ABBE E55
1j1' fV �/ r" • hl PHONE Ll 1 FlyL PANELS 5.00 DATE OF APPLICATION
' ARCHITECT SIGNS 6,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH,OR ENO' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANT IS MOTORS SEE FEE SCH. �T
ADDHEss
Dtrz � SERVICE CHANGE 10.00
,00 LICENSED CONTRACTORS DECLARATION Z' - /
a U U I hereby affirm that I am licensed under provisions of Chapter 9F I Z I} ^ 1 ' ISSUANCE DATE
n a w (commencing with Section 7000)of Division 3 of the Business and BLDG- ELECT. PLG. MECH.
F H z se
Code ao EI license is in full for Xml c J..4. ❑
iE. License Clu Lie.Number .a-
o D Date r� Contactor - rao' •.0; t Bt ;j(D ❑
c x f BUILDING:P.ERMIT"
a m w¢ OWNER-BUILDER DECLARATION IN FORMA210N.�
w 3 a r I hereby aoll. that I am exempt from the Contractor's License MISC.-
REFER TO ORD
v, Code:Any
reasonchne, msli Bunt Wc-dtlol'essions PERMIT ISSUANCE 6.00 VALUATION $/FT.
r - Code:Any city mom
n pair any structure p rior to consuanc alter,
ELEC.CONTR. LIC.NO.
¢ 2 0 Fo improve,demolish,or Repair any structure,prior signed its issuance,also ELEC
- D LL fe is tic the dp ursua too such permit to file a Com statement That TOTAL PERMIT TO
he is licensed pursuant to the provisions Rel the Contacmr s License
F z r
Law(Chapter 4)(commencing with Section 70000of Division 3 of the
PLUMBING PERMIT FEE'
¢ Business and professions Code)or that he is exempt tlmrefrom and QTY.
IS f o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
ate _ by any applicant for a permit subjects the applicant toacivillmnalty ALTER-DRAIN&VENT-WATER (EA.) 4.00 MwQ S',&WC
of ml more than five hundred dollars(8500).1:
C1I,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
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
hinLSClf or through his own employees,provided that such improve-
mentsarcnotameodedoroll'coed for sale.If,however,the building AS-EA.SYSTEM-11NC.40UTLETS 4.00
i
ur ole, 'totem 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- RES/ IND CON PB Omar
prove for purpose of Sale.). INDUSTRIAL WASTE INTER. 20.00
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
Occowd contractors m construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and I'ro(essions Code:The 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 fur inch projects with a contactor(s)licensed pursuant to
BE,Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
(:I I um exempt under Sec.-,BAP.C.lie Was WATER HEATER W/VENT 4.00
Reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPF-NSATION DECLARATION WATER TREATING EQUIP- 4.00
1 hereby unarm that I have a certificate of consent m self-D'ure, ZONING ENG.SITE NO.
or a certificate of Workers Compensation Insurance,or a certified
copy thereof(See.3800, piny 1.
policy No. Company j-
U ❑ trial Died copy is hereby furnished. I FIRE$PRINK ENERGY T 24
�Ccrlil"ed opy is hl;q W021le city inspection division. REFER TO ORD.
Z O ApplicanL�`_ �'z (616 MISG.- Y ❑ ry❑ Y❑ N❑
Fro PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.C.
CC CERTIFICATE OF IiXF:MPTION FROM WORKERS'
(this section nOIMPFiINSATIIOIN pleted INSURANCit [lie I'pcnnil Is for one PLG.CONTR. LIC NO. PLG.TOTAL Y❑ N❑ Y ❑ NE]W
d � be
::) Z Imndred dollars(5100)or Ic..) - n"
U O 1 certifythat in the performance of the work for which this per- Y. 'FEE,SUMMARY
QTY. MECHANICAL PERMIT FEE +•C:,'.em twls•.
LL F mit is issued,I shall not employ any person in any manner sn as to
OW bee omesu I II t Workers'C rtlpensal'ySn Uwe of Cali(orn ia.
n Dale/ Applicant t' .C' 'Z'�-= ALTER OR ADD TO MECH. 4.00 BUILDING H
} m NDTICE T( PLICANT: If,after making this Certificate of Ex-
♦- Z_ empoon,you slmuld 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 permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE .S?l
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 UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address-
1 certily that I have read this application and state that the above VENTILATION FAN (SINGLE) 3A0
information is correct. I agree to comply with all city and county BOILER-COMP 13 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and slate laws relating to building construction, and
go hereby annlori, representatives of this city to enter upon the g01 LER-COMP lover lOg000 BTU)SEE FEE SCH. MECHANICAL
shove-mentioned property for inspection purpoxs.
(We) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments,costs and expenses which CONST.TAX
may in any way accrue against said City in consequence f the PERMIT ISSUANCE 3.00
gmntipg of lhl penniL MECH.CONT- LIC.NO. MECH.
�IczCuw //_/� lJ/ TOTAL TOTAL �f
Signature of Applicant/Contractor Date
OFFICE COPY -