4796 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUI LD ING PROJECT I DENTIFICATI ON ' - PERMIT,NUMBER
aDiLDiNG APPLICATION & PERMIT
ADDRESS 47-96
^ '
. rtAA)� f-4U� 1BUILDING-ELECTRICAL-PLUMBING NICAL
-MECHA
OWNER'S
NAME PLAN CHECK VALIDATION
CITY. ELECTRIC PERMIT FEE
r �• l,!-1d hem 6,11. PRONE
CONTRACTORS•
NAME , 1 C`ok.S OUTLETS-SWITCHES-RECEP 5.00/1.00
ATLI FlA�IA14_ LIC N0. �_rp�e fE(a LIGHTING FIXTURES 5.00/1.00
-- - - -CONTRACTOR S APPLIANCES'_RESIDENTIAL 4.00 '
ADOR C..
It LA J j•3� �!, s. ). PHONE rS y_ j,R� PANELS 5.00 ' DATE OF APPLICATION
' ARCHITECT I PLAN CHECK FEE I P.0 NO '
OR SIGNS 6.00 Ill
ENGINEER
1 uc NO. I SIGNS TRANS. 3.00 1
ARCH OR ENG PERMIT VALIDATION
• ADORESE SPECIAL CIRCUIT '5.00 '
ZIP TEMP. METER OR POLE INS. 15.00 ,
ADD IESS , MOTORS SEE FEE SCH.
ADDRESS . .
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATION- J
Fu c 1 hereby affoin that nm licensed under Pniv"To"'of Cli:yner N - - ISSUANCE.DATE
a (commencing with Section ]000)of Division 3 of3 ih1 I BLDG. ELECT. PEG
o i Po,essmns Co ¢ease IS in full fo n eUc ❑ ❑ ❑
o i o License Class s -.110V
L L.Numberk
r w Dare Q Contractor _
-'J
Y a
OWNER-HUILDER 1 Is DECLA RA"PION BUILDING PERMIT
Fa o a O INFORMATION
; w I hereby affirm that I am exempt tram the Contractor's Lu.ense• MISC.- REFER TO ORD I 1:
1- .. 04 Lawfor Thefollowingremon.(Sec 7031.5,n�sinessanJProl'esvom PERMIT ISSUANCE 6.00 I VALUATION $/FT
E W N`C Code Any city or county which requires a permit to construct,alter,
¢ is ¢ o improve,demolish,or repair any structure,prior to its iauance,also ELECn CONTR. LIC.NO. ELEC
LL requires the applicant for such perm ment'lh
it to file a signed stxteul I'! TOTAL PERMIT TO
e. w$ he is licensed pursuant to the provisions of the Contractor lacenx
F i o Business andrProfesslo a Code)olr that he is exempt TherefromlanTd CITY. PLUMBING PERMIT FEE . .�1/�•�
¢ F m the basis for the alleged exemption.Anyy,unimmn Df S,CImo 7031.5 sTORIE3' TYPE CONSTR.
ate - by any applicant fore undyed abRCts(SSOID h<untmucrvil penally ALTER-DRAIN VENT-WATER (EA.) 4.00
of not more than five hundred dollars(5500)j'
❑ 1,a,owner of the property,or my'employees with wages as (BACK FLOW PROTECT. DEVICE 2.001 ocC.GROUP .I RE5 UNITS thn e 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. 4.00
Code.The Contractor's License Law does not apply to an owner of
property who builds Or improves thereon,and who doe,Such work IFIXTURES-PER TRAP 4,001 I so.FT,FLOOR AREA TOTAL ACREAGE
hnmself,or through his own employees.provided that such improve-
ments are not intended orodured for sale.If,however,the building l.t IGAS-EA.SYSTEM-1'INC.40UTLETS 4.001 1
or improvement is sold within one year of completion, the owner 1 GAS-EA.SYSTEM-OVER 4 (EA.) ,1.001 I BUILDING USE
' budder will have the burden of proving that he did not build or mr Omar RE5 iND CON PR .
prove for purpose ofsalcl 1 INDUSTRIAL WASTE INTER. 20.001 1
❑ I,as owner of the property,am esclusivcly contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors In vonsinict the proiecT tSrc ntra-liumnew LAWN SPRINKLERS- 1 INC 5 V.B. 5.001 '� ASSESSORS PARCEL NO
and Professions Code,'I he Contractor's License Law Jnez nm apply
TO In,
n owner of property who builds or improves thereon,:and who I, LAWN SPRINKLERS-OVER 5(EA.) 1.001
contracts Tor such projects will,a ort,actorl,)Ieensed pursuant Oi S EWER-SANITARY-STORM'EA.200ft/8.00 1
the Contractor',License Law. 1 I TRACT NO. I PARCEL NO
❑ I am exempt tinder Sec ,tl&P C:ol Oust iWATER HEATER W/VENT 4.001
reason
Dm• _ -Dwncr WATER SYSTEM 4.001 ACC DATE ACC.FILENO
WORK ERS'COMPENSATION DECLARATION - WATER TREATING EQUIP. 4.001 '
I hereby affirm that I have a certificate of consent m sellansure,
or a ceretiffiic�ate off Workers'Compensation Inmurunce,or a It"I" ticedi n O ZONING I ENG SITE NO,
copy th ,.iN(ulllY �I �7 �
Pnllcy
Q ❑ CcRihcd Copy is hereby funusher: .� L �r FIRE SPRINK ENERGY T-24
Z Z �CertiO d copy Is Zile with the say mspectwn Arvision —
F O A"Thcam_ _(���-�fJC - J '. 1MISC.- REFER TO OR D. I Y ❑ IN Y ❑ N❑
In PERMIT ISSUANCE
� „CIIIfI'IPICKFIi OF IiXfiAl l'I'ION PROhI WORKISRSI 6.001 '>, 1 FLOOD ZONE AD.u.c
W > COMPENSATION INSURANCE PCGICCNTR LIC.NO PLG
1 0 (This Section need not be completed if the permit its for one I I TOTAL I v❑ N❑ v ❑ ' IN
D Z hundred dollar,IS 100)or lea,.) ..+ -
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F inn is Issued, I shall not employ any person In any manner so as m
O W become subject to the Workers'Compensation Laws of Cahforne.
Date Applicant BUILDING
n ALTER OR ADD TO MECH. 4.00
} m emptioE 'I'O APPLICANT, If,after making this Certificate of lux-
F Z emption,you should become subject to Die Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE '
U such provisions or this permit shall he deemed revoked AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGISNCY ' I AIR HANDLING UNIT(OVER l0=C.F.M.)'5.0 SEISMIC FEE
I hereby affirm that there is a construction lending agency for ' EXHAUST HOOD (WITH DUCT) 2.001
the performance of the work for which this permit its issued ISe�. MICROFILM
3007,CIv.0 I. f HEATING UNIT(TO 100,000 B.T.U.) 4.001 irti
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.P.50 .I
_ Lender's Address I ELECTRIC
I certify that l have read this application and state That The above VENTILATION FAN (SINGLE) 3.001 1
information is correct. 1 agree to comply.wvh all city.and county PLUMBING
ordinances and star, laws relating to building constrictlom.apd I BOILER-COMP(3H.P.or100,000B.T,U.) 4.001
'hereby aWhorirc representatives of tills city 10 enter upon The
above-mentmneel property for inspection purposes BOILER-COMP (Over 100,000 BTU)SEE FEE SCH.1 I MECHANICAL
' (We) agree TO save;mdenmd'y and keep hurmles, lire City of MISC.- REFER TO ORD. 1
Cupertino against Iwbddies,judgments, costs and ex pens ITS which PERMIT ISSUANCE 3.00 p O CONST.TAX
may Ia tiny way accrue against said City at cnnseq uence of the I 3.0
Or Yng 01 fit Pr ❑.- ' MECH.CONT LIC:NO. MECH.
CI c� 0Z.7^85-
TOTAL I TOTAL /I
gnalure o Appllcant Coniractoj Date
OFFICE COPY ,