6796 APPLIC4 T TO FILLAN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTI FICATION .16 PERMIT NUMBER
RUI LDING APPLICATION & PERMIT
ADDRESS '� 1 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 6796
U G
OWNER PLAN CHECK VALIDATION
NAME fly'° QTY. ELECTRIC PERMIT FEE
.E:✓y IL(FHorvE �7 �2Q`V ��S
NAME Acrons OUTLETS-SWITCHES-RECEP 5.00/1.00
Iuc.No. LIGHTING FIXTURES 5.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL ' 4.00
ADDRESS
�m Qr- Qct PNONE q -&_` O PANELS 5.00 DATE OF APPLICATION
ARCHITECT J SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
R G�haI uc.No. SIGNS TRANS. 3.00
ARC H.Cs ENG. - SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
waInv1 cpse
O N a
J L�wa ZIP TEMP.METER OR POLE INS. 15.00
APPLICANT MOTORS SEE FEE SCH.
ADDRESS
2 r va VA f t, P SERVICE CHANGE 10.00
o o LICENSED CONTRACTORS DECLARATION
<o U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
N rt w (conuncuring welt Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F H z Professions Code and my license is in full force and effect
z oro - License Clash)(, SLax/Lic.Number ❑ ❑ ❑
mH Date }/��� Contractor
a y :E —��""/�� µ BUILDING PERMIT
¢ or w u OWNI'R-BUILDER DECLARATION INFORMATION
R
O 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
u , VALUATION $/FT.
r .. o j Law for the following reason.(Sec.703 L5,Business and Professions PERMIT ISSUANCE 6-00
Cade:Any city or County which requires a permit to construct,alter,
¢ he ¢ 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. /
i w m¢ re<luires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
F z a
Law(Chapter 9(commencingwilh Section 7000)of Division 3 ofthe r/LA.R.. f,fTc
4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE /
Or 1 o the basis for the alleged exemption.Any violation of Section 7031.$ STORIES TYPE CONSTR.
Ate _ by any applicant fora permit subjects the applicant toe civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(SS00).):
❑ 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROup RES.UNITS
their sole conpensalion,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 Com e hm'S License Law does not apply to an owner DI'
pm,cuy who builds or improves themon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOORAREA TOTALACREAGE
• himself or through his own employees,provided that such improve-
memsarenotintended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4-00
or improvement 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-
prove lot purpose ofsale.). INDUSTRIAL WASTE INTER. 2000 RES IND CON PB Omer
❑ 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. 5.00 ASSESSORS PARCEL NO.
and Professions 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 lilt such projects with a contracturis)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I ant Exempt under Sec. ,BAP.C.IYu this WATER HEATER W/VENT 4.00
mul11
Owner Dale WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPFNSATION DECLARATION WATER TREATING EQUIP. 4.00 /x( -
I hereby affirm that 1 have a certificate of consent to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified a N ZONING ENG.SITE NO.
Oily thereof(Sec.3800,Lab.C.). _
Policy No. /,.%.. .Company //r+'/�GG'f/7/�/dA
O' ❑ Cerlil'iml copy is hereby famished FIRE SPRINK ENERGY T 24
Z Z DrCert ifie else is Fl d with the city inspection division.
/ c MISC- REFER TO ORD.
Q AplI1CJ111 x11� /�..(- Y ❑ N❑ Y ❑ N❑
� N CI:R1'IP,,I�C^^A'fEVVO0.0.F�G�R�IS�d/hrP1'ION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOOZONE A.L.uc.
L �_ COMI IiNSA1'ION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ Y ❑ N❑
O
(This section need nut be completed if the lurmil is for one TOTAL �,
- Z, handled dollar.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
L H mit is issued,1 shall not employ any Person in any manner so as to
U become subject to the Workers'Co p sa tion Lawsof Ca lenificaifornia.
O a Date Applicam �P s ALTER OR ADD TO MECH. 4.00 BUILDING J1J r'
} to NOTICE'f0 APPLICANT: If,,�fte�m king Thinking This C
Z of lz,-
emption.you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Lubar Code, you must forthwith comply with FEE
U such provisions or this permit shell be deemed rcvokal. AIR HANDLING UNITT(TO 10=C.F.M.) 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER IOMC.F.M.) 5.00 SEISMIC FEE
I hereby of firm that there is a Construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the perfunnance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). A�/L HEATING UNIT(TO 100,000 B.T.U.) 4,00 _
Lender's N:une HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I C
Lender's Addles=
I certify that l hevy.,cad this afplicat ion and state that the above VENTILATION FAN (SINGLE) 3.00
informalion is correct I agree to comply with all city and county PLUMBING
ordinahrnes and state laws relating to building construction, and BOILER-COW(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 FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City oIMISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
gmnlingof this permit. MECH.CONT. LIC.NO. MECH.
5evvaWrArc � &C d TOTAL TOTAL
n ur
Signature of Applicant/Contract r Date
INSPECTOR COPY ,