2435 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY .
BU I LDING PROJECT I DENTI FICAT107N PE r
IT BR
BUILDING APPLICATION & PERMIT _ 435
ADDRESS
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BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
L7G �'1 _- _ _. _ _ _
OWNER'S - PLAN CHECK VALIDATION
NAME .� - `Z`j'3.gcjcj.Q QTY. ELECTRIC PERMIT FEE -
• ��\ 4C_is PHONE
croRs
.A.E OUTLETS-SWITCHES-RECEP 5.00/1.00
NAME ' ` mac/
uc No.JIC� LIGHTING FIXTURES 5.00/1.00
CONTRACTORS, �JAPPLIANCES-RESIDENTIAL 4.00
I W I ��vnw � y� PHONE '\1j IS PANELS 5.00 DATE OF APPLICATION
ARCHITECTSIGNS 6D0 PLAN CHECK FEE P.C.NO
. .
OR I
ENGINEER LIC.No. SIGNS TRANS. 3.00
AARCH,OR DDRESS ErvG, SPECIAL CIRCUIT - 5.00 PERMIT VALIDATION
z EMP.METER OR POLE INS. 15.00 n
AANTS
ADDRDDREESSSS , MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
O o - LICENSED CON'I'RAC'fORS DECIiARAT1ON
a u w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y z 'w (commencing with Section 7000)O(Division 3 Of the Business and _� 1 BLDG. ELECT. PLG. MECH.
H w z Professions Co a y license is in full force' effect. -
z o w - Live Cla" - - L".Nunhcr_ ES 2 �.y �j; "' - 21 ®, ❑ ❑
2 0 0 Datc f-S-�_Cmdractor
eN- 2 BUILDING PERMIT
OWNER-BUILDER DECLARATION INFORMATION
F.
;LL y I hereby'affirm that 1 am exempt from the Contractor's License MISC.- V O EFER TO ORD
LL O sc Low far the following reason.(Sec.7031.5,Businessand Professions `. i� VALUATION 8/FT.
_ PERMIT ISSUANCE 6.00 (o i
Cody:Any city or county whiny structure permit tots issuance.
.also �(
2 5 Q improve.demolish,Or repair any structure,prior n its issuance,also ELEC.CONTR. LIC.N ELEC. {/!�
- o u he is licensed
the applicant for such permit to file a signed statement that TOTAL/ PERMIT TO
n w m m he is IicenseJ pursuant to the provisions of the Contractor's License -
Hzs- Law(Chapter 9(commencing with Section 7000)o(Division 3 of the
Business and Professions Codc)or that he is exempttherefrom and therefroand QTY. PLUMBING PERMIT FEE
H Oo the basis for the alleged exemption.Any'dolation of Section 7031.5 STORIES ? TYPE CONSTR.
to 3 m by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
Of not more than five hundred dollars($500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEV ICE 2.00 ocC.GROUP RES.urHrts
their sole compensation,will do the work,and the,mutase 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 doesnot apply to an owner of '
property who builds or improves thereon„and who does such work -' FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or Ihrough his own employees,provided that such improv,- _ -
Pivots are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS q.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 for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB Omer
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ '❑
licensed contractors to con9trpOl the project(Sac. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor',,l.ianse Law docs not apply
to an owner Of prop,Ry.velm builds ur intprovc,lienor,and,who LAWN SPRINKLERS-OVER 5(EA.) 1.00 -
contracts for such projects with a comractods)licensed pursuant to
the Contractor'sLicense Late. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ .I am exempt under Sec. ,B.&P.C.,lor this WATER'HEATER W/VENT 4.00 '
Dam Owner WATER SYSTEM - 4.00 ACC.DATE ACC.FILE NO.
W'ORKI-IRS COMPEN'SAr'ION DECLARATION WATER TREATING EQUIP, 4.00
hereby alit. that I have a certilinde of consent m sett-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Conipensat'mn Inssurlecu,or a cvrt.t I
copy thereof(See.3800,Lab.C.) CL- '�jr7-KL�34^ 1
Policy No. Company[/-�
O ❑ C'rldicdopy is hereby furnished. FIRE SPRINK ENERGY T 24
Z z (tied copy i tiled with the city inspection division. MISC.- REFER TO ORD.
O Applica c. - v ❑' IN V E] N[]
w CERTIFICATE OIr EXEMPTION P tOM WORKERS' PERMIT ISSUANCE' 6.00 FLOOD ZONE A.L.D.D.
L COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. y❑ N❑ Y❑ N 1:1CL 0 (This section need not be completed if the permit is for one TOTAL
Z) Z hundred dollars(SIOO)or less)
U O 1 crudy that in Gte Pcrl'arltlance of the work f iF which If,,,I,,, QTY. MECHANICAL PERMIT FEE FEE SUMMARY
EL F mil is issued,1 shall not employ any person in any t,,arm,,so as to
U beconm'subject to the Worken'Compcosation Laws of California.
wDate A licam _ BUILDING G
OL PP
} 0NOTICE TO APPLICANT: If,after making this Certificate.of Ex-
ALTER OR ADD TO MECH. 4.00
Z mention,you should became subject ht the Workers'C,,npens:diott APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Codc, you most forthwal, c,mply with FEE
U such provisions or this permit shall he deemed revoked.r AIR HANDLING UNIT(TO 10pm C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10pmC.F.M.) 5.00 SEISMIC FEE
I hereby A ism that there is a construction landing agency tit, EXHAUST HOOD (WITH DUCT) r 2.00
the performance of fit,work fonwhich this permit is iS,LUJ(Sce. MICROFILM
3097.Civ C) HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name• HEATING UNIT(OVER100,000B.T.U.)7.50 ELECTRIC ,
Lender's Address
I certify that 1 have read this application can state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I carve to comply withall city and courtly PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.or100,000B.T.U.) 4.00
hereby malm,me re Presentatires of this city to enmr upon the
BOILER-COMP(Ove
above-mentioned property ti,r inspection purposes. r 100.000 BTU(SEE FEE sCH. MECHANICAL
(We) agree m save, indemnify and liven harnless 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 consequence of the PERMIT ISSUANCE 3.00 -
granting ofthis permiL MECH.CONT. UC.NO. - MECH.
-� Z orAL TOTAL
Sia amre of AnP mon[/Contrich Uutc - '
OFFICE COPY