8698 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PEHMIT NUMBER
UILDES
ADDRS
N APPLICATION & PERMIT i ����
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IU(a7G ft�1TPJJC . BUILDING-ELECTRICAL-PLUMBING-MECHANICAL /
OWNERS 1
NAME LT L/. PLAN CHECK VALIDATION
• . QTY. ELECTRIC PERMIT FEE
l 1 -
J (�c.r
E. PHpNE � 4a•y a+"
NAAMERAcrpRs '/ UTLETS-SWITCHES-RECEP 10.00/1.00
II 1 / �� &I LIC.NO,A Zq - 0 L111, LIGHTING FIXTURES 10.00/1.00
CONTITACADDRESS rpRa ST. `+ APPLIANCES 4.00
(e SS CGMM [4 (LLI C-L,PRONEl7 (Jz'>>�- PANELS 10.00 DATE OF APPucgnory
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
L.C.No. SIGNS TRANS. 3.00
ADDRESS ENc. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP fTEMP.METER OR POLE INS. 20.00
A0 ESsi TS MOTORS SEE FEE SCH.
ApORE
`
s JJJ
r U rM, Y7..�GI P'L >1. �• SERVICE CHANGE 20.00 �/ f
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE '30.00 S Y
a u I hereby affirm that I ton I eco,ad under provisions of Chapter 9 `a ISSUANCE DATE
Zrw (commencing wish Section 7000)of Division 3 of the Business ant n G N BLDG. ELECT. PLG. MECH.
H m i License CI Codc and my Heins,is in full('ore•and effect.
Z o rn 0 License Clens- ��_Lic.Number X11-p4/1.�
OO - D Date __Cnntrudor ,r
Hw
P
BUILDING PERMIT
a al ¢ OWNIiR-0BUILDER UECLARA'fION
¢o a v INFORMATION
wg LL H I herby affirm that Ium exempt from the Contractor's License MISC.- REFER TO ORD
uo J Law for the following reason,(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
� - Code,Any city orrounty whichre(juiresapermitlocov
nsucLq
allC
a ¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. UC.NO. ELEC.
o¢ requires the applicant for such permit to file o signet statement)hal TOTgI ,
wm he is licensed pursuant In the provisions of the Contractors License PERMIT TO
>
Law(Chapter 9(commencing with Section 7000)of Uivision3 oCthe
i4o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
ar I o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ;m by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN&VENT-WATER (EA.) 6.00
of not more than five hundred dollars(5500).1:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 14.00 Oce.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. 5.00
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 5.00 Sa FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees.provided that such ira prone-
ments are not intended or offered for sale If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or ira- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 C1 El El El El
I,as owner of the properly',am exclusively contracting with
s; licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for Snell projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ tum exempt under Sec ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner, - Date WATER SYSTEM 5.00
ACF DATE ACC.FILE N0.
WORK FRS'COMII I'ION DECLARAITON WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of corlwat to sell'-insure.
or a certificate of Workers'Compensation Insurance,or a Certified ZONING FLING.SITE NO.
copy thereof)Sec.3500.Lab.C.1
Policy No. ConlpanyF'1i.OdL7..^7 r . r Ii
O ❑ Certified!copy is herehy)urn ' FIRE SPRINK ENERGY T-24
Z Z ❑ Certified opy is tiled ith the ity inspection division.
H Q Applicant �� y7 �1�ti1 X MISC.- REFER TO ORD. Y❑ N❑ Y ❑ No
rn RST' PERMIT ISSUANCE 10.00
LU CIiR'1'IPICATIi OPEA'iIONMIPPIONNSURONIW'ORKE FLoOo ZONE A.L.u.c.
W � C'OMI'1>NSA'I'I(JN INSURANCE PLG.CONTE. LIC.NO. PLG.
0- Z (P
his section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
hundred dollars($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,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensatioo Laws of California.
W DaIc��Applicmd< _ v - ALTER OR ADD TO MECH. 5.00 BUILDING
} 0 NOTICE TO APPLICANT: IC after making this Certificate o fix- (�
F" 2 emption.you should become subject to the Workers'Compe lion APPLIANCE 5.00 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.) 4.00
CONSTRUCTION L17NDING AGENCY AIR HANDLING UNIT(OVER 10PMC.F.M.) 6.00 SEISMIC FEE S�
I hereby affirm that there is a comtrumion lending agency for EXHAUST HOOD (WITH DUCT) 5.00 -
the performance .Ithe work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building csmlruction, ant BOILER-OOMP(3 H.P.or 100,000 B.T.U.) 6.00
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. d
(We) agree to love, indenulify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against hathililics, judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
rally in any way recruit against said City in consequence of the
gmntingof'lhisperinit. MECH.CONT. LIC.NO. MECH.
TOTAL(� . .. and/C � , I ate -i TOTAL 03 G z
Signature of A}Splicanl/Contractor � Date _
INSPECTOR COPY