7067 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINTNEN ONLY x
BU LDI NG PROJECT I DENT]FICATI ON PERMIT NUMBER
y B ,Lp,NG APPLICATION & PERMIT 7U67
I AooREss �1
.21760 STr�c�usG K P�+O BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME61 �) � OTY. ELECTRIC PERMIT FEE
• U/� �1 `VI PHONEL � J�.L�
. cross
NAME CSC s.0 1- UTLETS-SWITCHES-RECEP 5.00/1,00
NAME
14196
t} ,Q-J LIC.No. 1�? LIGHTING FIXTURES 5.00/1.00
r CONTRACTORS PPLI ANCES-RESIDENTIAL 4.00
ADDRESS -Z:-? O CikKh�U�JA•
L PHONE2 QC /-'37( 1 PANELS 5.00 DATE OF APPLICATION
PLAN CHECK FEE P.C.NO.
ARCHITECT pie 4. SIGNS 6.00
NGINEER
LIC,No. SIGNS TRANS. 3.00
/ +P,ERMIT VALIDATION
ADDRESS ENG �"=j OLD q1(O I.���EI..1> SPECIAL CIRCUIT 5.00 p
z, EMP.METER OR POLE INS. 15.00S ' _
AP" MOTORS SEE FEE SCH. /��\I(/'/T/(
ADDRESS b �c hyo t=
J l•J'-"' SERVICE CHANGE 10.00
w o D LICENSED CON'I'RACSORS DECLARATION
LE o U s I hereby affirm that 1 am licensed under provisions of Chapter 9 ,r ISSUANCE DATE
t-G aan (commencing with Bc'ctinn 7000)of Division J of the Business and �. BLDG. ELECT. PLG. MECH.
F D z PRrlcssionc Code,mot my license is in full force andffect.
z o m License Claes /� / Lic.Nwnber �&/�7/ -
o H w Dale Contractor
BUILDING PERMIT
a w OWNER-BUILDER DECLARATION INFORMATION
E:
3 LL - I hereby affirm that 1 am exempt front the Contractor's License MISC.- REFER TO ORD VALUATION $/FT.
t u O j Law tirt the following reason.(Sec 7031.5.Business and Professions PERMIT ISSUANCE 6.00 �•
Code:Any city or county which requiresa permit to construct.alter, IJV
LIE
¢4 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. �/ OU y
e- S c u relplires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w mhe is licensed pursuant to the provisions of the Contractor's License
rzi
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe O�Fy� C` �L J6-
< Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
the basis for tire alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ; by any applicant for a Permit subjects the applicant to it civil penalty ALTER-DRAIN&VENT-WATER (EA.)
m
of not ore Chn five hundred dollars($500y): V'S/
O I,as owner.1 the property.or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
Iheir sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00 k
Code:The Contractor's License Law does not applyto an owner of
properly who builds or improves thereon,and who dues inch work FIXTURES-PER TRAP 4.00 SO.Fr.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve- y
GAS INC. 0UTLETS q.p0
mems are not intended or offered for sale If.however.the budding 5w SL7
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA) 100 BUILDING uSE
builder will have the burden of proving that he Aid not build or im- . . .
RES IND CON Pe Diner
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ L as owner,ot the property,am exclusively contracting with El El ❑ ❑ 11
licensed contractors to construct the project(Sec.7044.Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
?' and Professions Code The Contractor's License Law does not apply _
to an owner of property who builds or im,00cs thcrcon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts 1'o,such projects with a Limitations)licensed pursuant to
'�. the Contractor License law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NOr
'❑ 1mucxcmpt under Sec.-,B.&P.C.lit this WATER HEATER W/VENT 4.00
y anon
/ Owner Dine WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COAII'HN$ATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I Iwvu a certificate of con Ent to selfmir ure. ZONING ENG.SITE N0.
or a certificate Of Workers'Compensation Insurance,or a certified
copy thcrcof(Sec.3800,Lab.C.). ./ f2 a
Policy-No. Company 444-2004 -
Q ❑ Cenlfied copy'is he by furnished. FIRE SPRINK ENERGY T74'-
Z 2 ❑ CertificA mpy filed with the ylly_i¢speetion division.
p Applicant I -,; i-•� ,,.--� MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ NO
iy CE RI FICATE bl:17XEM111[ON I7ROM WORK Ii RS' PERMIT ISSUANCE 6,00 FLOOD ZONE A.L.0 c.
UJ � Cols NSATION INSURANC17 PLG.CONTR. LIC.NO. PLG. v❑ N❑ Y❑ N❑
EL 0 - This scclilin need not be completed if the permit is for one - TOTAL
hundred dollars(5100)or Iess.l
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
UL H mit is issued,I shall not enmloy any person in any manner so as to
U become subject to the Workeri Comp;nsat ion Laws of CaIII'ornlu.
O w BUILDING S-D
0. Dale Applicant ALTER OR ADD TO MECH. 4.00 7 .S
} m NOTICE'1'0 APPLICANI: If,after making this Certificate of 14s-
F. Z emption,you should become Subject to the Workers'Compensation APPLIANCE - 4.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions m this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is Ii construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the perlormance of the work for which this permit is issued ISce. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00_
Lenders Addyess
Lender's AddrHEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that I have read this application mid stale Ihst the above VENTILATION FAN (SINGLE) 3.00
. infonntion is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
and
ordinances and state laws relating to building consvuclum,
hereby authorize re Presenmtives of this city m enter upon the BOILER-COMP (Over 100,000 BTUf SEE FEE SCH. MECHANICAL
abuve-mentioned properly for inspection purposes.
(We) agree to save, indemn nd keep-I"_lesstheCity of MISC.- REFER TO ORD. .
Cupertino against Ira INE", dgnt n[s, co i a td expenses which - CONST.TAX
may in any ay ,rue inst.(aid Ci in/couse9uence of the PERMIT ISSUANCE 3.00
Simon o hISp mLL. MECH.CONT. LIC.NO. MECH.
--. TOTAL TOTAL �Ip
igna ore of'Applicant/Contractor Date .I `• \ .. �
INSPECTOR COPY