5429 APPLICANT TO,FILL'IN INFORMATION WITHIN RED LINES--.USE BALLPOINT PEN ONLY
BUI LOING PROJECT I DENTI FICATION - PERMIT NUMBER s. -
BUILDING - - . - ' APPLICATION,& PERMIT -
'\ ADDRESS •-� � - - •' A //��y'1
boy. �F7�1s `J� �� BUILDING—ELECTRICAL—PLUMBING-MECHANICAL 5TL1V
OWNER'S'. - - ' PLAN CHECK VALIDATION
AME'
DTV. , ELECTRIC PER 11 FEE
'�,- �V• PHONEF ti . i. 'hw i4 k ` E ms' 'T ti`•K
CONTRACTOR'S
a NAME �Z - OUTLETS-SWITCHES-RECEP 5.00/1.00 .t
s" � i
LIGHTING FIXTURES:, ' 5.00/1.00
CONTRACT OHS L /• ,
,ADDRESS L'[� APPLIANCES:RESIDENTIAL' .4.00 -
��a cr)na PHONE PANELS DATE DATE OF APPLICATION
OR
CHITEC - SIGNS 4,. 6,00 PLAN CHECK FEE P.C.NO.
,ENGINEER - I
LIC.NO. ISIGNSTRANS., `'.; 3.00
ARCH.OR ENG. - - PERMIT VALIDATION
ADOREss - SPECIAL CIRCUIT, ' - ' '5.00
e
zIP EMP.METER OR POLE INS "j-7115.00
+ APPLICANTS - C
SEE FEE.SCH
J
ADDRESS MOTORS,.
SERVICE CHANGE 10.00
¢Oo LICENSED CONTRACTORS DECLARATION P- - +'.
•Q u E, 1 hereby affirm that I am licensed under provisions of Chapter 9 / ,
z w - 16UANCE GATE _ -
(etmmencing with Section 7000)of,Division 3 of the Business and
Professions and my license is in full fore•' d eIT '• BLDG. ELECT. MECH,
lass - „ Lic.Number - - ABR 11"7 IM El
o ate Con&actor .r +LL LJ
E
Y `Y
¢ ¢w 4 OWNER RUILDER DECLARATION BU Lp�p{IN MIT
X 3 u y' I hereby.al'f¢m thaLl am exempt from the Contractor's Luense MISC.- -REFER TO ORD & CI usP& y
u O j Law for the following reason,(Sec.7031:5,Busuiex,ro d Professions VALUATION - $/FT.
- PERMIT ISSUANCE 6 -
Code'Any city or county whicrequiresa permit toconslruct,alter, .00 /OO
IF
¢ ¢o Improve,demolish or repair any structure,prior to IIS issuance,also ELEC.CONTR. LIC N0. - ELEC.
¢ requires the applicant lot such permit to file a signed statement that TOTAL
he is licensed pursuant to the provisions of the Contractor's Licenae - ,a - PERMIT TOf 7,9L 1
-H � rt
Law(Chapter 9(commencingwith Section 7000)ofDwision 3 of0ie �!. Vv,fqi
• i D Business and Professions Code)or that he is cxcmprthcrefrom and GTV. "fPLUMBING�PERMIT 4 i a' t `FE �/C-r/(yd/✓/r�-' Zi9.1�
g v y a a a *» 'gym = *:" .
¢ H $ the basis plicae alleged exemption.An violation oto action malty �* � - a R , .: _ STORIES TYPE CONSTR.
a 3 by any applicant fora u permit sub/eats the applicant to a civil penalty -
of nofinore than fivehundred'dollars($500).): ALTER-DRAIN&VENT-WATER'(EA.)'4.00
❑ 1,as owner of the,property,or my employees with,wages as BACK FLOW PROTECT:DEVICE.. 200
their sole compensation,will do th ,
e work,and the structure is not OCC.GROUP RES.UNITS
intended oroffered for sale (Sec. 7044, Business.and Professions DRAINS+FLOOR,ROOF,AREA,'CON D.'•4.00
Code: The Contractors License Law does not apply to an owner'ol' -' '- ;
property who builds or improves thereon,and who does such work FIXTURES-'PER TRAP ':" 4.00 50.FT,FLOOR AREA TOTAL ACREAGE
,himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM 1 INC.4 OUTLETS, 4.00
or improvement Is sold within lure year of completion,the owner- GAS-EASYSTEM OVER 4(EA`.Y
builder will have[he . -
burden Of proving that he did not build or im-. - `,1.00 BUILDING USE
. . prove foi purpose of sale.). I. 1` INDUSTRIAL WASTE'INTER RES ' IND CON PB Otter'
❑ I,as owner of the property, -20.00 0 �,
P P y,am exclusively contracting with _ _
licensed contractors to construct the project(Sec.7044,Business - LAWN SPRINKLERS-1 INC 5,V,.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code.The Contractor's Licensc Law does not apply
In an Owner of property who builds or improves thereon.and who LAWN'SPRINKLERS-OVER 5 (EA.) 1,00
-
contracts for such projects with a contractor(s)Iicensciffmouanl to
the Contractor's LicenseGaw.
SEWER-SANITARY-STORM EA.200ft/B.00 TRACT NO, PARCEL NO.
'❑ 'I am exempt under Sec. ' ,B.&P.C.for this
f '•reasoWATERHEATERW/VENT.
4,00
owner
- Dme`. WATER SYSTEM .'4.00 ACC.DATE ACC.FILE NO.
WORKF,RS'COMPENSATION.DBCLARATION WATER TREATING EQUIP."., 4.00
I herrhy affirm that 1 have a certificate,of consent to selihnsure, 7or acertificate of Workers'Compensation Insurance,or a certified - ZONING ENG.SITE NO.
copy thcreof(Scc.3800,Lah.CJ.
Policy NO ComFlany
O - ❑ Certified wry is hereby furnished'. r't -
z Z, st+3�CelI on divisi n _ - FIRE SPRINK, ENERGY T24
FO pplier MISC.- ',REFER TO ORD. 'Y EJ: N[n Y❑ N[
PERMIT ISSUANCE 6.00
m CF.RTIF ICATE , PTIONFNOM�WORKERS' FLOOD ZONE A.L.U.C.
L > COMPENSATION INSURANCE PLG; u0.
CONTR. . NO.� PLG.
EL O .,(This'Section need not`he complemd-if the recruit;
for one d TOTAL Y O N� V(] N�
D,Z hundred dollars($100)Orless.1 _ _
V O I certify that in the performance of the work for which this per- "•'viagg. kt FEE SUMMARY
LL F mit Is issued,I shall not employ any person in any manner sous[o QTY. MEDHANIDAL4PERMIT FEE a u'9.�,;
O.W become Subject to the Workeis'Compensalion Laws of California L E .a: `T{ a ss -s-'a tm'1i.�iy
y Dam Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
}'0NOTICE TO APPLICANT: If,after making.Ihis,Certificate of Cz-
F Z emplion,you should become subject to the Workers;Compensation APPLIANCE. 4.00 'PLAN CHECK '
provisions of the Labor Code, you must forthwith comply with q p. 93'
such provisions or this permit sliall be deemed revoked. '- AIR HANDLING UNIT(TO 10,ODOGFEE F.M.) 3-00 - �"�
,, CONSTRUCTION LENDING AGENCY. j. AIR HANDLING UNIT(OVER 40p00C,F.M.) 5,00 - 'SEISMIC FEE S
I'hereby'affirm that there is a'construcGon lending'agency for EXHAUST HOOD(WITH DUCT) 2,00
the p rf'rmance of the work.for which.this permit is issued(Sec. MICROFILM
3097 Civ.CJ. . ' „ HEATING UNIT(TO,100,000 B.T.U.) 4.00
Lender's Name -
Lender'sAddress'+ - HEATING UNIT(OVER 100,0008.T.U.)7:50 :ELECTRIC,.;
Icerhfy thailhaveread this application andslluethat thcabo'e VENTILATION FAN (SINGLE) 3.00 - -
'mfonnahon is correct. 1 agree to comply with all city and,cot0ty BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordmames.and stale laws relating to budfim�
ding coaslrucand
hereby, authorize representatives of this city to toter upon the BOILER-COMP IOval 100,000 BTU)SEE FEE SCH. MECHANICAL'
above-mentioned property for.inrepresentatives
of this
purposes.to '-
(Wc)"agree to save, indemnify'and,keep harmless the City of MISC.-- " REFER TO ORD.
Cupertino against liahihties,-judgments,:costs penses 4 PERMIT ISSUANCE , •CONST.TAX
may In any way cote against said C' consequence of Ihe. n, 3.00
grunt' this r i[. ' "' MECH.CONT.- - LIC NO MECH. -
TOTA
L TOTAL �JL
ignature of Applica antra, Dale - '�
nr
- - OFFICE COPY '. .