3731 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
i 4•` Y PERMIT NUMBER
BU I LDING PROJECT IDENTIFICATI ON I .APPLICATION Si PER MIT.
aDDRE55
12 0 `CALbgI? (BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OwNER'S 6 - PLAN CHECK VALIDATION
{ NAME
-�4MA^� - OTY. ELECTRIC PERMIT FEE-
T
0?AD) ARDloMJa✓q DNEl'r(y'jto�
CONTRACTOR'S
NAME //'^.�_� ^�1��QQ �/ OUTLETS-SWITCHES-RECEP 5.00/1.00 yC( "-
DUVV OW l_.O�N.IST' LO Ll,c�rvro.l37Y1-16 ps LIGHTING FIXTURES.' 5.00/1.00
.- -rorvrRACroR's y!�/Gi4F(��MVr ' APPLIANCES-RESIDENTIAL 4.00
aDOREES / ``�/
' PRONE 71 PANELS DATE OF APPLICATION'
ARCHITECT, 210 bZb SIGNS -6.00 I 4PLAN CHECK FEE P.C.NO. '
OR
ENGINEER
..bu \/ 1 - `ISIGNS TRANS. _37 -
WOJ I-,�NG ..t1AY
ARCH OR ENG Y �' PERMIT VALIDATION
ADDRESS n .I ^ISPECIAL CIRCUIT' 5,00
.,Zlyv c"0. yRk S? Z'ARLS / METER OR POLE INS. 1 l 5 APPUCANrs - I �EMP.
OTORS 111 . /�f'D -J ADDRESS ERVICE CHANGE 10.00 ry pQ/
w o o LICENSED CONTRACTORS DECLARATION S/a/OT
Q'ir w I hereby dffirin that I am licensed under pfOVISIOIIS of Chapter') ISSUANCE D
yz Iconunencmg with Section 70001 of Division 3 Of the OUVmess mil
Q 6L I BLDG. ELECT PITi`� CH
r w z Professions Code, m httmL is m full fore a effe
o z v, o Dr Class_ Lie NUmbcr ®_.
H r Duir!'_ 'u-/. Contractor — x
a m s J / 7 r BUILD.IV ERM
N 'a - OWNER-HUILDERDLCIARATION
S 0 W v - INFORMATION
. 3: LL 1 hereby affirm that I dm exempt from,the Contractors License MISC.- REFER TO ORD It
iso¢ Law for the following reason, 7031,5,BUSInesS and Professons VALUATIO
_ PERMIT ISSUANCE 16 — I Y U Iq
fw0 Code.Any City or county which Requires a permit to construct,alter,
6.00 T
ES Q O improve,demolish,or repair any structure,prior to Its AoamCC,dISO ELEC CONTR •LIC.NO - ELEC. -
o.lc iequat,the dpphcanf fur such permit to filed signed statement that TOTAL S I
iL uwmA iv.ls licensed pursuant to the provisions of file Contractors License' � c�•. PERMIT
Law i o Hosn ms aadrPtofesiAones Code)olr(hat he is eve1'of thircfrom and OTY. PLUMBING PERMIT FEE I b. �(/���• '
IS tire the has,for the alleged exemption Any violation of Section 703151- ). STORIES TYPE CONSTR
u g by any applicant for a permit subjects the applicant toa civil Penalty -9
of not more than five hundred dollars(S500)1.(• . ALTER
-DRAIN& VENT-WATER (EA.) 4.00 � afn/��
❑ I,as owner at the property,or my,and flees with wagesds BACK FLOW PROTECT, DEVICE 2,00 ( � I OGG GROUP RES.UNITS
Then sole Owner onion,well do the work,and the stwith re n not
uvcndcJ or afle,ed for sale (SCI 7044, RUSmcss and PO.lcssons DRAINS-FLOOR,ROOF,AREA,COND. 4.00 I R•3 /
"Code The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work 7 FIXTURES-PER TRAP 4.00 SO.FT FLOC AREA TOTALACR FACE
1M1ts.1 - himself or through tits own employees,provided that such improve-r
penis are not Intended or offered for sale 11,however,Ihebuddin GAS-EA.SYSTEM-1:INC.40UTLETS 4,00 2/0
v build pr will have( is sold burden o one year of completion, me owner- (GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 I BUILDING USE
,yr builder will have the burden of proving that he did not baled w er- �LM�{-}''�
Q'`✓j'�Pi 1w p rove for purpose of sale 1 (INDUSTRIAL WASTE 14T WD I RES IND . CON PH Omer
❑ I,as owner of the property.am CxcLuwcly contracting with 20'00 z ❑ ❑ ❑, ❑
licensed contractors to construct the.prolect ISee 7044,OUSUmss 1 ILAWN SPRINKLERS- 1 INC 5 V,B. 5.00 . IILLii ASSESSORS PARCEL NO. -
and Professions Code 1'he Contractor.',License Law does not apply
to an owner of property who builds or improves thereon,and who { LAWN SPR I N KLERMkVEPr 5 (E 1.00 2 �Z l - 54 Se•- ODS-
c n races for such projects with a contractor(s)licensed pursudm to • SEWER--SANITARY-STORM -
EA 20Oft/g00
the Contractor's License Law. TRACT NO PARCEL NO
❑ Idm exempt under Sec. ' li ail'C for Dia
Uut•'n l WATER HEATER W/gh*_13t GU{)e1Lp14.00 /
reaso '
�wnri 1' / WATER SYSTEM ' 4.00 lie 1, ACC DATE ACC FILE NO o
ArORKERS•C0MPI1NSATION DECLAKA'IION I WATER TREATING EQUIP, 4.001
I hereby atlirm that 1 have a cernficule of consent to a'll-insure;
or a certificate
q/`off Workers'Compensation Insurance.or a certdled a I I ZONING ENG.SITE NO.
copy thereyf/�3�QO.Loh GL((�� G,--^ 't . 59n1,P,//,546
Policy NO Yj;aLp,,h) '7]j
0 �Cerldied copy' s hvmby lurAAishe FIRE SPRINK ENERGY RI4
Z Z ❑ Certdind//�W133y cud with' Its c�-..A41;, Jivninn.1. MISC.` - REFER TO ORD.
X O Applicant FROM ! - I ' Y ❑ N❑ V ❑ .
SO PERMIT ISSUANCE- I
Lu CE RTIF CCOMPENSATIO 1'INS FRONI W'ORKISRS' 6.00 6 •I cE000 ZONE A.LU C +,
W � COMPENSATION INSURANCE PLG.CONTR u0.NO PLO. /�
D' 0 I"thin section need not he cons Pleled if the permn i. Inn one I TOTAL rP O y❑ N❑ y❑ N❑
0 2 hundred dull...(41001 nr Icm I i
U O I cenlfy' that m the Fort oumancc of the work for which nos per- OTY. MECHANICAL PERMIT I FEE I- FEE SUMMARY
LL H con us IssueJ�l Atoll not employ any person In any manner s0 es t0 _
OW become subpol 10 the WodCrs'Com,ca,,(um Laws of Cald o nu.l
CL Date Apphcnnt BUILDING
} N NOTICE 't0 APPLICANT If,after making this CCrtuhcam nl lix- ALTER OR ADD TO MECH. 4.001 I
Z emption,you should become subject to the Workeri Compensation I-r— APPLIANCE 4.001• 1 PLAN CHECK
.provisions of lire Labor Code, you must for(hwilh comply with FEE.
'U soch provi,loln or Dus permn shall beacon ed revoked. ` AIR HANDLING UNIT(TO 10=C.F.M.) 3.001
CONST'RUCT'ION LENDING AGENCY 1 . AIR HANDLING UNIT(OVER i0�=[6c ) 5.001 '.SEISMIC FEE
Lh tr
e.Cby aft,rm than there' is a consuct TUn Icnding agency for 1 EXHAUST HOOD (WITH Durok � 2.00 I
the performance of the work lot which this permit Is issued(tier: MICROFILM ". I I
3097,Civ.0 1 � �� HEATING,UNIT(TO 100,000 B.T.1)a�
Lender's Addoc -' ' � HEATING UNIT(OVER �3
Lender's Address MP,400B. U.1`/.50 ELECTRIC `SD
I cernly that I have real this apphcd con and slate that the above VENTILATION FAN (SING LE)�,,(C fp.� - -- f)
\ information is correct I agree to comply with all city and county' BOILER-COMP(3 H.P.or 10pp��yyRRPO . PLUMBING 6d
pordinances and sloe laws relating to bulldin Construction, and 1Wy 4.00
' henhy awhnn<e representatives Of Dus my to emu upon (tic l BOILER-COMP (Over too, BTU(BEE FEE SCH. MECHANICAL
above mentioned property for impecUnn purposes _
�—�. -(We) agree to save, indemnify and keep humdcs, the CA, oI MISC,- REFER TO ORD.
Cupertino against habdittes, iudgmenls, casts nil PERMIT ISSUANCE i 3.00 CONST.TAX I,
may In any way accrue against said Qt uI C eq -
grantingof i pe cot MECH.CONT LIC NO. MECH I QY
TOTAL TOTAL 7Z 3
Sigmdar• I'Apphcan(/Con• eta. )ate
OFFICECOPY -
'Y -,.