16508 APPLICANT TOcFILC IN.INFOFIMATION:WITHIN RED LINES— USE BALL POINT PEN ONLY ' -
•,'PERMIT NUMBER
BU I LDING PROJECT I DENTIFICATIOW,
BUILDING — ;APPLICATION & PERMIT
IO<'�i'7�S . /nide f 'Ley BUILDING -
ELECTRICAL—PLUMBING—MECHANICAL
OWNER'S , - PLAN CHECK,VALIOATION
"nmlj. /yam QTY. I ELECTRIC PERMIT'
FEE
PHONE
CONTRACTOR
ONTRACTO 'S. 5� LUTLETS-SWITTUCHES-:REEP10.00/1.00
IHTG� c. 0RES 10.00/1.00
. / � u ,
_
P
coNTRACTOR's APPLIANCES-RESIDENTIAL 400 -
ADDRESS p 1 - S„Q..,•
3.3��Yt�Oc RjuZ PHONE )y6}'107 r/ PANELS 1000 PATE OF APPLICAT
It I.
ARCHITECT - a. PANELS (OVER 200 AMP) -20,00 ;PLAN CHECK FEE <P.C.;NO.
OR,
;r ENGINEER •• „ -
LIC.NO. SIGNS TRANS. - .3.00 .
ARCH OR ENG. SPECIAL CIRCUIT.
5.00, - PERMIT VALIDATION ,
ADDRESS _ {
,EMP.METER OR POLE INS. ' _,.20.00
APPucarvrs MOTORS 'SEE FEE SCH.
ADDRESS � Ly
La )V SERVICE CHANGE. 20.00
00 LICENSED CONTRACTORS DECLARATION .
U u 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE GATE
y ¢Ic (Commencing with Section 7000)of Division 3 of the Business and, - BLDG. ELECT. PLO. MECH.
H i Professions Cotle�,and myy license is in full force and efl'e 7
'z o — License Class ,fL Lic.Number�e r o
- ❑
o_N L 0 Date a:4 2•-P? Contractor r 2 _ - -
¢ BUILDING PERMIT' -
¢ o n OWNER-BUILDER DECLARATION , - .,INFORMATION
X I hereby affirm that I am exempt from the Contractor's License 'MISC.- .' REFER TO ORD
a, S u VALUATION $/FT.'
-FU0< Law for following reason.(Sec.7031.5,Business and Professors PERMIT ISSUANCE - - 10.00 �, x�'
Code:Any city or county which regmresa permit to construct,alter, -
Qor ¢ � Improve;demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. I� - A
D'¢ requires the applicant for such permit to file a signed statement that ,C ,. TOTAL LSo PERMIT TO
he is licensed'pursuant m the provisions of the Contractor's License , T, -
Hzi
Law(Chapter 9(commencingwith Section 7000)ofDlvismn 3 ofthc - j „•
¢ Business and Professions Code)'or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢H o the basis foe the alleged exemption.Any violation of SectioR703L5 _ STORIES TYPE CONSTR.
a ;m' by any applicant for apemlhsubjectsthc applicant Goa civil penalty ALTER-DRAIN -WATER (EA.) 5.00 '
of not more than five hundred dollars(S5001)', `
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP ' RES.UNITS
sole compensation,will do the work,and'the structure Is not
intended*or offeredrunsale (Sec. 7044, Business and Professions DRAINS-FLOOR1 ROOF,'AREA,COND. 5.00
Code;The Contractor's License Law•does not apply to am owner of -
property who builds or improves thereon,and who does such work " FIXTURES-PER TRAP- 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- - ..
-• mems are not intended or offered forsale.,If,however,the building GAS-EA:SYSTEM=1 INC.4 OUTLETS 6.00 _
or improvement is Sold within one year of completion,the owner- GAS-.EA.SYSTEM-OV ER4(EA.) 2.00 BUILDING USE
builder will have the burden o'provingdhat he did not build or am- RES 'IND CON; PB Other
prove 1,aso of sale.).' . ''" INDUSTRIALWASTE INTER: '30.00
❑-I,as ownernee of the property,am-exclusively'contracting with
licensed contractors to construct the project(Sec;7044,Business LAWN SPRINKLERS-1 INC,5 V.B. °P 6.00 sASSE350 5 PARCEL NO.
and Professions Code:The Contractor's License Law does not apply - - -
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.)t 1.00
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. 'TRACT N0. PARCEL NO.
❑ lam exempt under Sec.' ,B.&P.C�'i'or this WATER HEATER_W/VENT - 6.00 -
reason
Owner Date WATER SYSTEM + '' 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP.' 4 15.00 .
„. I hereby affirm that I have a certificate of consent to self-insures '
or'a certificate of Workers'Compensation Insuiance;'br'u certified " ZONING - ENG.SITE NO.
copy thereof(Sec.3800,Lab.CJ.
Policy No1>.,07 ri Company er1-4 r J'c•N•
O ❑ Certiftedcopyishereby furnished FIRE SPRINK- ENERGYT2A
Z 2 K Certified copy'I1��,fe{�d ith the city in pection division.
O, APplamm . Y//6 ,ar�� , MISC.- .. fl yO N� y No
~
T - PERMIT ISSUANCE 10.00
CERTIFICATE.OF EXEMPTION FROM WORKERS' - FLOOD ZONE - A.L.u.c.
_ W > - - COMPENSATION INSURANCE PLG.CONTR. LIC:NO,- PLG.
-� (This section need not'be comple@d if the-permit.is for one TOTAL V N .V N
hundred dollar,(S 100)car less.) ' -
0 O 1 certify that in the performance of the work for which this per, FEE SUMMARY'
LL 1- mit is issued,I shall not employ any person in any manner so as to QTY. MECHANICALPERMIT FEE
O become%objec[m the Workers'Compensation Laws of California.
O i Date' Applicant 1 BUILDINGALTER OR.ADD TO MECH. 5.001,
} IS NOTICE TO APPLICANT: If,after making this Certificate of Ex- -
- H ? emption,you should become subject to the Workers'Compensation APPLIANCE + - 5.00 - PLAN CHECK
provisions of the Labor Code, you must forlhwitli�comply with FEE
C7 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 r..
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE ,
d hereby'affirm that there''is a construction lending agency for EXHAUST HOOD(WITH DUCT)the performance of the work for which this permit is issued(Sem' - - 'MICROFILM
3097,Cie C.). HEATING'UNIT(TO'100,000B.T.U.) 6.00 1
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ' I�FS�
Lender's Address - ELECTRIC'
�I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00_ '
information is'correct. I agree to comply with all city and county I + - - , PLUMBING
ordinances and state laws relating-to building construction, and ,BOILER-COMP(3 H.P.or 100,000 B.T.U.)"6.00
_ hereby authorize representatives,of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. ' MECHANICAL
above-mentioned property for inspection purposes• -
(We) agree to save, indemnify and keep harmless the-City of MISC.- REFER TO ORD. -
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE` .10100 CONST.TAX '
may In way accrue arist said City in consequence of the . -
Inn[i" f IS permit _v. - MECH.CONT v LIC.N0. MECH
(J/ LJL- • e� /-/z d'/" TOTAL TOTAL
Signature of'Applicant/Contr oast r Date
OFFICE COPY,