4851 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LD ING PROJECT I DENTIFICATION PE MIT NUMBER
BUILDING APPLICATION & PERMIT 4851
�a ADORE s
/ 3 7 a R v ,e 1�2 BUILDING -ELECTRICAL-PLUMBING-MECHAN ICA OwNER'S 1J 0 in
PL VALIDATION
91111111111116
NAME u� 9g6 9&9 TY. ELECTRIC PERMIT FEE 4
PHONE p 199
CONTRACTOR 5 \1
NAME UTLETS-SWITCHES-RECEP 5.00/1.00
D.Cum ;Air. {plumb CIC,No9a 55 V ILIGHTING FIXTURES 5.00/1.00 COpe�\{\0
nwT Ess TORS APPLIANCES-RESIDENTIAL 4.00 OR
�\Y
3/f ,( /•I ?,C D R PHONE 1a 3-4a4 I JPANELS 5.00 DATE OF APPLICATION
ARRCHITECT SIGNS 6,00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARC H.OR ENG. PERMIT VALIDATION
ADDRESS SPECIALCIRCUIT 5.00
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH. \�11A
SERVICE CHANGE 10.00
woo LICENSED CONTRACTOkS DECLARATION
a u I hereby affirm that 1 am licensed under provisions of Chapter 9ATE
m a vai
(commencing with Section 700e I of Division 3 of the Business:mA BLDG. LECr. PLG MECH.
F v, 'Professions C e nd my license is in lull Horsey aye rfJ'Prt. ❑ ❑ ❑
z o w - License:Class (,�_Lie.Number
o w Ua[eJ_7_4=By__Contractor
ZIx Q w ¢ OWNER-BUILDER DECLARATION BUILDING PERMIT
w °nU MISC.- REFER TO ORD INFORMATION
; u H I hereby affirm that I am exempt from the Contractor's Lirovsc
LL o f Law for lire following reason.(Sec.7031.5,Business and Professions VALUATION $/FT.
- PERMIT ISSUANCE 6,00
Code:Any mty otor mu my which structure P prior
tots issuance,
,also
R 2 ¢ p improve,demolish,or repair any structure,prior to its issuantt,also ELEC.CONTR. LIG NO,In
ELEC.
u
re requires the applicant for such Permit to file a signed statement IIm1
o u TOTAL
d w m he is licensed pursuant to the provisions of tire Contractor's License PERMIT TO
zaLaw(Chapter 9(commencing with Section 7000)of Division 3 of the
4 o Business and Professions Code)or that he is exempt therefrom andOTV. PLUMBING PERMIT FEE
re H o the basis fnr the alleged exemption.Any vmlmim,of Sectiorl 7031.5 F
I STORIES TYPE CONSTR.
u by any applicant for a permit subjects lire applicant to a civil penalty
of not more than five hundred dollars(S500).1: ALTER-DRAIN&VENT-WATER (EA.) 4.00 -
❑ I,as owner.1 the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do OIC work,and the sl roc tore is not
imended or of Herself for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 4.00
Code:The Contractor's License Law does not apply m an owner OI'
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 SO.FT,FLOOR AREA TOTAL ACREAGE
• himself or through his own employees.provided that such improve-
Hoots are not immndcd or offered fur sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
Of improvement is sold within one year of completion,the owner-
builder will have the burden of proving slut he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
Prove for purpose of sale.). - INDUSTRIAL WASTE INTER. 20.00 Rs I❑ ❑N ❑ p❑
❑ I,as owner of the property,um exclusively cont rad ing with
licensed contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
mad Professions Code The Contmdor's License Law docs nut apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.1 1.00
contracts forsueh projects with n cunlractorts)licensed pureu,nl to -
IhcContraclor'sLicenseLaw. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ tare exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT
reason 4.00
Date Owner WATER SYSTEM 4.00 Ace.DnrE ACC FILE No.
WORK IiRS'COhIPfiN'SA'I'ION DECLARATION WATER TR EQUIP, 4.00
1 hereby affirm that I have a certificam of consent to self-insure, fl
or a certificate of Workers'Compensation Insurance,or a certified U ZONING ENG.SITE NO-
copy thereof(Sec.3800,Lab.C.),
Policy No. Company
O ❑ Certified opy is hereby furnished.
Z Z 19 CerI fA ltd c'u Py iz ff d yil1, the city inx'peiliun division. V� FIRE SPRINK ENERGY T 24
FO Applicunl�__.7 (E - n I
SC.- 0 REFE 00 D. y � N� r � N�
CC CISR'I'IFIC'ATIiOb-IiX1iMP1'IONI'RONIw'ORKI'RS' RMIT ISS A CE 6.00 FLOOD ZONE A,L.u.c.
Lu � COMPENSATION INSURANCE
R. LIC.NO. PLG.(This section need not he completed if tlne pamil is for one TOTAL v N V ryZ hundred dollars(S 100)or less.I
U O I certify that in the performance of the work for whichthis per- MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any Immner so as to
Ow become subject to the Workers'Compensation Laws of California.
y
Date-Applicant ALTER OR ADD TO MECH. q-p0 BUILDING
} 00 NOTICE TO APPLICANT': If,after making this Certificate of Ex-
F ? emption,you should become subject to tire Worker,'Connpens,Iion APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be decnned rcvokcd. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00 FEE
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby ,firm that there is a construction Icnding agency for EXHAUST HOOD (WITH DUCT) 2.00
the perfnrmancc of the work for which IN,permit is Rued(See MICROFILM
3097,Civ.C'f HEATING UNIT(TO 100,000 B.T.U.1 4.00
Lender's Name
Lender's Address 4BOILER-COMP(3H.P.orlOO,000B.T.U.I
ATING UN IT(OV ER 100,000B.T.U.17.50 ELECTRIC
I certify that I have read this application and,tate Ihat the aboveNTILATION FAN (SINGLE) 3.00
information n correct. 1 agree m comply with all city and county PLUMBING
ordloemLs and , re laws relating to is building c nst r non, and 4.00
hereby ,uthoriee representatives ec this city e, enter upon the BOI LER-COMP (Over 100,000 BTU)SEE FEE SCH.
abovrmm�tioned property fnr inspedimn purposes. MECHANICAL
(We) agree to save, indrininfy and keep Ium,less 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 conseq Hence of ILL. PERMIT ISSUANCE 3.00
g nn ,ung of[his pemlt. MECH.CONT, LIC.NO. MECH.
v`at• iacan yLG�-td ll/.UTIQI.n J_
IO_ •7 rDTAL TOTAL
Signature of Appbcan[1Conlract r 13, e 7 '
,rp OFFICE COPY