6673 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 6673
AODREss
) [✓ /�' e BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME
/ OTV. ELECTRIC PERMIT FEE
/<e
PHONE ifl7 '- 5�c/ PAID
CONTRACTORS
NAME UTLETS-SWITCHES-RECEP 5.00/1.00
L77e1[IJ
11114, uc.No.l7�✓�'- LIGHTING FIXTURES 5.00/1.00 JUN 181984
CONTRACTORS -a PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 5.00
OR
SIGNS 6.00 PLAN CH K FEE .NO.
ENGINEER
ihc.No. SIGNS TRANS. 3.00
ARCH,OR ENG. PERMIT VALI DATION
hADDRESS SPECIALCIRCUIT 5.00
- ZIP fTEMP.METER OR POLE INS. 15.00
ADDRESS MOTORS SEE FEE SCH. ('all
`( d
PrUC '
r - - • - SERVICE CHANGE 10.00
w
' 09 LICENSED CONTRACTORS DECLARATION �-
a .w I limehy affirm Ilmt I am licensed under provisions of Chapter 9 9tSUANCE DATE
v, 4 N (commenting with Section 7000)of Division 3 of the Business and �� L ELECT. PLG. MECH.
r m z Professions Code d h a Ise is in full farce; d f ec�Za./ -�
,e o m -• License Class Lie.Number- ❑ El 1:10 - 0 Date Conlmclor
F w H J
y BUILDING PERMIT
as OWNER-BUILDER DECLARATION
d m w o • - INFORMATION
oA. MISC.- REFER TO ORD
X
; r I here the follo that 1 am exempt from the Contractor's License
HLLoQ Law for lyefollowingreason.(See. uires a,ermit tocndtrct,a Ions PERMIT ISSUANCE 6.00 vALunnON E/FT.
Code:Any city or 6or my which requires e permit to construct,also
<0 improve,demolish,Or repair any structure,prior to its issuance,also ELEC.CONTH. LIG.NO. ELEC.
-0 n requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
whe is licensed pursuant to the provisions of the Contractor's License
R z a
Law(Chapter 9(commencing with Section 7000)of Division 3 oflhe /
Buiiness and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
at 1- the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
I_- by any applicant far a permit subjects the applicant toacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(S500L) /
❑ 1,as owner of the property,or my employees with wages as BACK F LOW 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 does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES•PER TRAP 4.00 SQ.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsannotintendedoroffered for sale.If,however,the building GAS-EA.SYSTEM•11NC.4 OUTLETS 4.00
or improvement is'snld within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the trader of proving that he did not build or im-
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 IND CON PB Omar
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to un owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contracoms)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO.. ,PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPISNSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to slit Gin.vue' ZONING
or a certificate of Workers"Compensation Insurance,or a certified ENG.SITE NO..
copy thereof(Sec.3800,Lab.C.). ��
Policy No-
0
oCompany V
0 ❑ Certitiedcopy ishereby furnished„ FIRE SPRINK ENERGY T-24
-Z Z ❑ Ce RIK �cmpy i Ol d d,I a cit' inspection division. MISC.- REFER TO ORD. y ❑ N❑ v ❑ N❑
O. Applicant- d,C
H Er rCiNT'IICI 017 EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00
FLOOD ZONE A.L.U.C.
W > COMPENSAION INSURANCE
PLG.CONTH. LIC.NO. PLG.
CL Z Ohis section need not be completed if the permit is for one TOTAL Y E] N❑ Y❑ N❑
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any person in miry,manner us as to
O w h cmnc u e<t a Workeri pemsaf n stpf lif r 4-
W Date-��ApPlicam ALTER OR ADD TO MECH. 4.00 BUILDING
}'m NOTICE APPLICANT: If,after making this Certificate of fix-
♦- Z ensption,you should become subject ur lire Workers'Compenailion 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 10PW C.F.M.) 3.00
CONSt'R UCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10A00 C.E.M.) 5.00 . SEISMIC FEE r
1 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.l. HEATING UNIT ITO 100,000 B.T.U.) 4.00
Lender's Name HEATI NG UNIT(OVER 100,000 B.T.U.)7.50
Landers Address ELECTRIC
( certify that lhave read this application andstate that the above VENTILATION FAN (SINGLE) 3.00
information is correct.1 agree to comply With all city and c0unly PLUMBING
ordinances and state laws relating to building cmnstruclion, and BOILER-CO 13(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 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, costs add expenses which - CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
granlln Of this mit. ,.t /J MECH.CONT. LIC.NO. MECH.
C eLI(l�c-s-c. C�G/FSI TOTAL TOTAL
Signai> Applicanl/Contractor Vate I ✓{
OFFICECOPY