5580 APPLICANT TO FILL,IN INFORMATION WITHIN RED LINES- USE BALL POINTaPEN ONLY
BUILDING PROJECT IDENTIFICATION - PERMIT NUMBER
BUILDING - _ APPL'ICAT'ION & PERMIT `
ADDRESS '
,2D��) `'I - •/' A.1,1/A. /� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
5580
..NER' ^���D(•r�/j_(L h+ 1p ` PLAN CHECK VALIDATION
r rJ,� OTY. ELECTRIC PERMIT FEE I `�Q 7�lT/•(((��/
PHONE
"ONTRACTOR'S OUTLETS-,SWITCHES-RECEP 5.00/1.00
C53,4ol So3
$� I
LIGHTING FIXTURES 5.00(7�:/ / _t .00
EDNTRACTDHS ry� ,O !APPLIANCES-RESIDENTIAL . 4.00
ADDRESS ) I 'p'//� �/�
�4C,J&)We AE-� /,MII.NE PANELS 5.00 GATE OF APPLICATION
6.00 PLAN CHECK FEE , P.C.NO.
oR^ SIGNS' , ]'l
ENGINEER �- ,
ucu-o'_' SIGNS TRANS. 3.00 ,
ARCH OR ENG PERMIT VALIDATION
ADDRESS I SPECIAL CIRCUIT '}5.00
ZIP. TEMP.METER OR POLE INS.
APPLI CANTS MOTORS SEIFr F4E CH. s
ADDRSS SERVICE CHANGE eJ�J L, t .Ol�:U9
Ole z /�•
r=o o I-ICIiNSIiU CONI'ItAC'I'ORS DECLARATION pp - _ '
v I henb (firm (hat I am licensed raider rovhsionsof Chu ter9 .l y^ ;a YI�y UI VO 8f[I Oo
Y n P P EL$G/ rd.Q ' YUO L P ISSUANCE GATE
(commencing
CnQQwith
auulSection
llC OOOjis of n(ullsforU3.�opf�ktire Business andl SLOG. I ELECT. PLG. I MECH.
oi_'o. License Class -'Lm Number
[)ate Conlractor
a m E BUILDING PERMIT
g w OWNER,BUILDER DECLARATION _ INFORMATION
.W ;°,°w I hereby or that I am exempt from the Conlractor' icons, MISC.- REFER TO ORD 1
u p¢ Law for the following ronson'(Sea 7031.5,Basmessand oresslons Oo VALUATI 5/FT
r Curb,Any city or caunly whlvhrclmneaa pennitluco tracLuln•r . PERMIT ISSUANCE 6.00
IT
m s( m eve,Jemobsh;or repair an stmcturc.pour to it issuance,also iELEC.CONTR LIC NO
Ic Q o ipr P Y IELEC ..yD �- /
DLL regains the applicant fur such permit In file a+ign statement that• TOTAL oC
n w m he'll heensed pursuant to the provisions of the C demtor's License H T
io BumehantdrP'olessonsnCoe)iolr Shat)he I00xempljlhereT.11 tnl _CITY. PLUMBING PERMIT FEE
I- °m the basis for the alleged exemption Any v' dtion of Section 7031 5 STO E. uprylgppPSTR.
a � by any applicant for d permit subjects lh applicant In a civil penalty ALTER-DRAIN&VENT-WATER (EA.14.00 _ ! N
of not more Than true hundred dollars 50011 I Grp /T�
❑ I,as owner of the Property, my employers with wabes as ' BACK FLOW PROTECT.DEVICE 2.00 OCC GROUP RES UNITS
Ihcu sole crnnpensation,will no •work,and the structure a nal . .
intended or offered for sale (S . 7044, Business and 1'ro1'esslons I 'IDRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code The Contractor's Licel Law does not apply to an owner of
property who builds or Ira )ve5 thereon,and who does such work I IFIXTURES-PER TRAP 4.00 1 SO fT.FLOOR AREA TOTAL ACREAGE
•� himself or through his ow employees,Provided that such unpro ve.
s ments are not intended offered for sale.If,however,the budding IGAS-EA.SYSTEM-1 INCA OUTLETS 4.00
or Improvemenhis so within one year or completion,the owner-I IGAS-'EA.SYSTEM-OVER 4'(EA.) 1.00 BUILDING USE
builder will have th urden of praying Thal he did not build or mr flE5 .IND 'CON PB Omer
IT forpupose salc.l. i I (INDUSTRIAL WASTE INTER. 20.00 : I ".�
❑ I,as own of the property;am exclusavalY cuntrxcOnp wd
• licensed comr tors to construct the project(Sec.7044,Business I ' ILAWN SPRINKLERS-1 INC 5 V.B. 5.00 ` ASSESSORS PARCEL NO.
and Protessl s Code The Contractor's License Law don not app].
to an owl of property who builds Or improves thereon,and who ILAWN SPRINKLERS-OVER 5,(EA.) 1.00
r cool met for such projects with a cuntructorfs)licensed pursuant ti
tire tractor's License Law 'SEWER-SANITARYEWDEA.200ft/8.00 - TRACTNO. ' PARCEL NO.
I am exempt under Sec.' ' ,B BP C.fort" (WATER HEATER W/VENT , . 4:001
Dr oil + __ _ _ __ _
O nor Dute I (WATER SYST@�UL .L 1 1984 4.001 ` ACC.GATE ACC.FILE N0,
WORKER$'COMPhNSAT'ION DELI-nRAT1oN WATER TREATING EQUIP. 4.00 a
• I licrehy a1Grm that I lime a L,rh Ocato of,orP;.H to eclf-uwiuc,I Clty Of�CUpB[tI00 1 1 ZONING ENG.SITE N0.
or a certlllcate'of Workers'Compens lino Insurance,or a certifieJ .r
�. copy the roof(Sec 3x00,lab CJ �''L ' 'L. /pV8� -'L- �oo L
Policy No Compun( -
Q ❑ Certified copy is hereby furnished. 6✓C Ia�'a'�I FIRE SPRINK ENERGY T 24
Z Z y� Cer p t Non division:
FO +Cpplicanl .. lk1.' �k�'c I (MISC.- REFER TO ORD. YE] NI] Y ❑ N1]
V5 CIi RTIIICA'I'Ii OP I?XIik1P1'ION PROM WORKIiR$' PERMIT ISSUANCE 6.00 CP w i FLOOD ZONE A.L.0 C.
W - f• CO4FMATION INSURANCE PEG CONTR. LIC.NO.- PLG. 9/GEO
d D 1I'hls secUan need not be',ompletel If the perm t is far one I TOTAL �C(P Y N Y N1]
Z humirtm( (Ian 181001 or IcssJ • -
U - r 1 certify i i alLe performance of wvmk orT which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY n�
IL F mil is Issued,1 shall no L person m any manner so as to _
U"U be'l7c'UH, it if n'CoEve fapJawsolCabfomia
D, Dmc' APphc:mt `� BUILDING �(�sa
' } m NO)IC' APPLICn N'I'' If after making this Ccrnf:OcTt Ii ALTER OR ADD TO MECH. 4.00
F Z. empNon,you should bicome subject to the Workeri Compensation APPLIANCE 4.00 I' PLAN CHECK
provisions of-the Labor Code, you must f6rthwmh comply with FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10J1000,F.M.) 3.00
- CONS I'RUcTION LENDING AGENCY'' I AIR HANDLING UNIT(OVER 10=C.EM.) 5.00 SEISMIC FEE I 77
1 herehy.affiren,t1w, Ihcu is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00 1
a the performance of the work for which this permit Is issued(ties MICROFILM I'
-3097,Cis C.). ;��Jr_ I HEATING UNIT IT0100,000 B.T.U.) 4.001 ,1
` Lender's Name �q
1.cndcri AddP-- I HEATI NG UN IT(OV ER 100,000 B.T.U:)7.501 I ELECTRIC dC0 00
Ieerily that l have read this uppbcaton and stale that the above VENTILATION FAN (SINGLE) 3.001 I p
nformatmn is wrrect. I agree to comply with all city,and county
ordinances
1 ordinances and ,into laws relating to building construction, and I ('BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.001 '1 IBC
hereby aulhoriie representatives of this city IO x
above-menNaned Properly fonnspecNOn purposos^enter upon the I BOI LER-COMP lover 100,000 BTU(SEE FEE GCH.I I MECHANICAL I'
(WC) agree to Save, indemnify and keep harmless the City of I 1-MISC.- REFER TO ORD.1
Cupertino against buhihties;judgmcnls, Lash and expemes whH,h 'PERMIT ISSUANCE 3:001 I CONST.TAX
in m any ay acy u against saud.City m consequence of the
gr� gn h I, n'. , •-f > �y,/ MECH.CONT. LIC.NO - MECH,
�tt _ w w� G C lie TOTAL I TOTAL �3.�
Signature Of App lcfnt/Contractur Dalc '
' OFFICE COPY L.