5298 �z> •"' APPLICANT TO FILL IN INFORMATION WITHIN RED LINES _ USE BALLPOINT PEN ONLY
BUI LDI NG PROJECT IDENTIFICATION! - PERMIT NUMBER
a ,LD,N� ,APPLICATION & PERMIT
aooness
V02,6 •�. ', BUILDING—ELECTRICAL—PLUMBING-MECHANICAL , 5298
OWNERS VVV��` PLAN CHECK VALIDATION
NAME - ; OTY. EL GTRIGP,E I FE
c Nrfl c ofl Ap ,)x UTLETS-SWITCHES-F ECEP 5.00/1.00
NFME ii'�J
uc.rvo.Z, LIGHTING FIXTURES a; 5.00/1.00
ADDRESS y .Qum PPLIANCES-RESIDENTIAL 4.00
Roi PANELS 5.00 DATE OF APPLICATION
OR -3 *-1313 SIGNS 6,0 - PLAN CHECK FEE � P.C.NO1�5 .y"
ENGINEEn •w,� �l -
SVL/� uc.No. SIGNS.TRANS. - 3.00
ARCHADDRESS OR ENG. - SPECIAL CIRCUIT ,5.00 - •PERMIT VALIDATION
/1110
t"_
, wrnP 9��j EMP..METER OR POLE INS. 1500q
AooflEss - T (Io/� MOTORS (' SEE FE 10.0
I SERVICE CHANGE 1000 ( ( /�
w o o LICENSED CONTRACTORS DECLARATION - :too p4o
< u 1 hereby affirm that I am licensed under provisions of CImptci 9
2 w +.\ ISSUANCE DATE'
to a$i (commencing with Section 7000)of Division 3 of Business and . BLDG.• ELECT. PLG: 'MECH.
F m z Professions Codd licenreus m full force ' ` ❑ ❑ ,❑ ❑
z o w - License Class—"e-2- Lhc.NumberIVY -
9 m F wDafe � Conlrac[Br�
JAN
-( C ryry
r r JAN 15 �O 3 BUIL'DINOjPERMIT
¢ ¢ w a OWNER-BUILDER DECLARATION Y - - +.
•..• INFORMATION
'w g LL w [,hereby affirm that 1 am exempt fromrthe Contractor's License MISC.=;'-, •.,•�n REFER TO QRD —
the •„,a” - VALUATION
r w.N J Law forAny
countywhing reason. Sec.hie 7irusa ermBusiness t towdProfessions PERMIT ISSUANCE x•Mye 16.00' S/FT.
Code:Any city or county which requirese permit to consuanc,also' `
Q ac <'Q improve,demolish,or repair any structure, to its issuance,also ELEC.CONTR. LIC.NO, rr ELEC. '
¢ requires the applicant for such permit to file a signed statement that TOTAL //
` � PERMIT TO
u w m" he is licensed pursuant to the provisions of the Contractor's License -
rzQLAW(ChaPtd,9(Commencing with Section 7000)of Dwh.hou 3 of
4 o Business and Professions Code)or that he is exempt therefrom and QTY >s PLUMBING PERMIT EE r/
¢ r o the basis for the alleged exemption.Any violation of Section 7031 S µA4 „'1, +t o-u'?':. m'eq°a STORIES '.TYPE CONSTR.
n ;m by any applicant fora permit subjects the`applicant loacivil penalty ,than
of not moALTER-DRAIN&VENT-WATER (EA.) 4.00
re five hundred dollars(1500)Jr ,�
U. I,as owner of the property;or my employees with wages as BACK FLOW PROTECT'.DEVICE 2,00
their sole,compensation,will do The work,and the structure is not OCC.GROUP, RES,UNITS -
intended or offered for sale(Sea 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 thererin,and who does such work FIXTURES”-PER'TRAP4,00 so.FT.FLOOR AREA roTAL ACREAGE
himself or through his awn employees,provided that such improve- - -
mentsare,not intended or offered for sale.14 however,the building .GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner,
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 * BUILDING USE
prove for purpose of sale:). - INDUSTRIAL WASTE'INTER'. 20.00 BES IND .CON•, PB ,Othar
U ,I,as owner of the properly,am exclusively contracting with - - � ,
licensed contractors to const,wFthe project(Sec.7044,Business LAWN�SPRINKLERS-1.INC 5 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's'License Law does not apply V.B..
• to an owner of property'who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5,IEA.) 1,00 i'-
conlracts.for such projects with a conlractots)licensed pursuant to
the Contractor's License Law. , . SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL No.
,0 .l um exempt under Sec. BAP.C.for this WATER-HEATER W/VENT 4.00
reason
Owner 'WATERSYSTEM 4.00 • ACC.DATE ACO.FILE NO.
woRKF:Rs'coMPENsAl]ON DECLARATION WATER TREATING EQUIP_ ' 4.00
I hereby affirm that'I hove a 'ertifiemc orcousent to self-incur',
or a'certifcate of Workers'Compensates surat,a ora certified ' ZONING ENG.SITE NO. '
uipy thereof(Sec 3800,Lab C.)./�G.
Policy No.—Company_✓( .. ,
0 *i Cr a by(urnislo,d FIRE SPRINK ENERGYTZG
Z Z p� e ' p it edion division
F 0 A'pplica - :, MISC - :>-REFER TO ORD. :y� N� v ❑ .-N� '
'CYNCERTIFICATE OF EXEMPTION FROM WORKERS" '-PERM IT•ISSUANCE ,. '6.00 ,FLOODZONE A.C.u.C.
LL > COMPENSATION INSURANCE' PLG.CONTR. LIC,NO. PLG. _
1 -(This section need'nol be completed if the permit is for'one TOTAL V N� V NO
Z hundred dollars(S 100)or less.) L, I I1,-yx µ - - -
U O _1'certify that in the performance of the work for which this per, QTsV * M CH NICAL PERMIT FEE EE 8U MARY
l.0 F
not 's issued,I shallnot employ any,person in any manner so as t s -w o
O become subject to The Workers:Compencatiom Laws of California ' r •"* -
y Date Applicant ALTER"OR'ADD.TOMECH. 4.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex- '
F Z emption,you should become subject to the Workers'Compensation APPLIANCE, 4,00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with PLAN* FEE
U, such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10,000C.F.M.)c 3.00
CONSTRUCTION LENDING AGENCY.,' AIR HANDLING UNIT(OVER 10=CF,M:) 5.00 SEISMIC FEE'
I hereby affirin that.ihere.is a constr tlon]ending agency for EXHAUST HOOD(WITH DUCT) 2.00
- the performance of.the work for which this permit is issued(Sec. MICROFILM
3097,Qv.C,) HEATING UNIT(TO 166,000 B.T.U.)- ,4.00 .
'Lender's Name - - v'-
Lender'sAddieas HEATINGUNIT OVER 100,000B.T.U.)7:50 ELECTRIC
t Icrtify,that l have ondthhsappl,caton and state that the above VENTILATION FAN (SINGLE), 3.00
information is correct+1 agree 90 comply-with all city and county PLUMBING
omi antes and-Aan, laws relating to building- onstruction; and BOILER-COMP„(3 H.P.or 100,0008T.U.)s400 ' '.s
' 'hereby authorize representatives of this city to enter upon-the
above-meutioneto section put ses. BOILER-COMPdlover 100,000 BTUI SEE FEE SGH. MECHANICAL
J pperty for inp
(w'e)'agree to Save,'indenmhfy and p I armless the City of MISC.- REFER TO ORD. - -
Cupertino against Ihabhlhhes,judgments cost and expenses which , CONST.'TAX -
may ny way"accrue against said 'ity j consequence of the PERMIT ISSUANCE " ° 3 00 _ h
I, o p• I MECH.CONT LIC NO
..STMECH., .n- aTxvk a° k xarx
.TOTAL 0 s q y
hgnature o Applicant/Contractor ,Dale t r { A m t• k ,�NTOT+QL$ q
s” .. -
:OFFICE Copy ,