5747s APPLICANT;TO FILL IN INFORM ATION-WITHINYRED LINES—USE BALL POINTPEN ONLY
4,
0¢2
,00
Q'U.
N 2 wU0
a AC
'H'y z
o N a
I-'
a y $ J
K 0
Le 3 6 N .
u004
E msc
I" a E O:
O p
x`m
ia
H
p h O
a 3 m
�o
LU
as
DZ
0
LLU
Ow
a
H � .
V.
BUILDING'PROJECT IDENTIFICATION -..'•
- •,
' APPLICATION & PERMIT :'"
A
BUILDING — ELECTRICAL— PLUMBING -MECHANICAL
'PERMIT NUMBER
, '• r n "
"�
SDILDi"Gr J^� p*�'-��y�/ t5,..
ADn RESa 0&.0 CJ NAV. UG..r�• �/�
7 ry;
OWNER'S.
"AME, f}P�LE ed�1P1/7c4_
'./"
°
QTY LECT�RIC PERMIT FEE
* y4 -,Y IIliIA -&I �. ,.+8 .
PLAN CHECK VALIDATION -
-
.,
.CONTRACTORS
NAME.
UTLETS-SWITCHES-RECEP 5.00%1.00
LIGHTING FIXTURES 5.00/1.00
*jerc".Skee''�fZf,•
,
CONTRACTOR'S �- S'r' / .�I(�'9.fC6-•:
-ADDRESS
APPLIANCES -RESIDENTIAL - 4.00
-
- PANELS _ 5.00
04D,IN L PRONaE 1.10\ i
'onTE OF APbucnnoN
�9'bR
ARCHITECT Ce. T' y/d � 36 g
OR d•
ENGINEER
- Lie. No?
SIGNS - 5,00
PLAN CHECK FEE • P.C. NO.
'SIGNS TRANS. .3.00' •-
ARCH. ORENG...500
AODRESs- .. r,
' zIr
SPECIAL CIRCUIT.,
PERMIT VALIDATION
/ I"•
EMP. METER OR POLE INS. 15.00, '
-APT S
nooaesS ` r
ar'
MOTORS' y,' SEE FEE SCH.
SERVICE CHANGE.- 10.00
LICENSED CONTRACTORS DECLARATION
_
-�
1 hereby affirm thaal am licensed ander provisions of Chapter 9
looaimearn, with Section 7000) of Division of the Business and
14ma si=, Code, and my licenseis in fall force and effect
bimnse C16ss-� :SC•�Q.ic. Number 1 1 L
ISSUANCE DA E
BLDG. ,ELECT. PLG... M H.
❑ ❑ -❑`
- - -
Data 9 - �- y Contractor' a.7•_'
_
-BUILDING�PyERML
INFOR.MA�1'_O.
_ •
'OWNER DECLARATIONM
' 1 hereby affirm that I am exculpt from the Con Gamor•s License,
Law;forthe following reason'(Sec_ 7031.5, Businessand Professions
Co - n [ o too strut! alter, drove y city r county rep it ah regn hie ,prior t e n I
improve, demolish, or repair any struemre; prior to its issuance; also
requires the applicant for such permit to filo a signed statement that
he Is fi emawd pursumll'to the provisions of the Contractor's License
Law (Chapter 9(commceringwhth Section 7000) of Division 3 ofthe
Business and 'P of s'h ns Code) on that he is exempt therefrom and
the basis for the alleged exemption. Any violation o(Section 7031.5
MISC. — REFER TO ORD
pERMIT ISSUANCE 5.00
VALUATION. $/FT.
'
ELEC. GONTR.. LIC- NQ
-
ELEC.
TOTAL
- PERIT TO
G ✓✓VV
STORIES TYPE CONSTR.
`.^* % kT. scot'$#,'
iw'„'W° k tax, "'x 'a'L''P
CITY: k d wPLUM131 NO PE RM ITL of 4 �F¢..EE,S
"li q ## T#'m'§�`a4 � Y.. R 3� � m�•'�"v.� �. t�' kT k"i �'"�
by any applicant for a permit object, the applicanito a civil penalty
of mh more than five )rundred dollars ($500). ):
..
ALTER-DRAIN&VENT-WATER(EA.)4.00
❑ I, as ownerof the property, or my'employees with wages as
'theigsole compensation;,will' do. the work, and the structure is not
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
.
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
'intended or offered for sale (Sec. 7044, rEuminess and Professions
Code' The Canimator's License Law docs not apply to an owner of
property who builds or improO there)n. and who does Such work's
hhmselLor through his own employees, provided that such improve-
awals am,not intended or offered for sale If, however, the building
- '-
•' 11•
FIXTURES; PER TRAP•' 4.00
SO, FT. FLOOR AREA
TOTAL ACREAGE
GAS-EA.SYSTEM-11NC.40UTLETS 4.00 ,
or improvement is sold with'n ote'year o1completion, the owner -GAS
builder will have the burden of proving that he did not build or am.
- prove for purpose of sale.).
•,❑ 1, as owner of the property, am exclusively contracting with
- EA. SYSTEM - OVER 4 IEA.)' 1.00
BUILDING USE
,RES IND CON PB Other
❑ ❑ ❑' ❑ ❑
INDUSTRIAL WASTEINTER'. 20.00
licensed conhactors to, construct' lire project (Sec. 7044, Business
and Professions Codc The Contmetm's License Law does rot"apply
to an owner (h1' properly who builds or improves thereon, and who
LAWN SPRINKLERS- 1 INC 5 V.B.'' 5.0.0
LAWN SPRINKLERS = OVER 5 (EA.) 1.00
'
,
ASSESSORS PARCEL NO. .
-
contracts for such projects with'a contractors) licensed pursuant to
the Contractor's Licmw Law:
SEWER -SANITARY -STORM EA. 200ft/8.00
9 TRACT NO. PARCEL NO.
1) Inmexemptunder Sec. ;;B.&P.C.for this
reason
-
-
WATERHEATERW/VENT- 4.00
Owner "•.Date
WATER SYSTEM •'-4.00ACC.
DATE ACC, FILE NO.
WORKERS'COMPENSATION DECLARATION ' ``
WATER TREATING EQUIP,- 4.00
• I heieby affirm that 1 have a certhiicute'of consent to.selLinsure,
or a certificate of Workers' Compensation Insurancep, or a certified
- -
20NING ENG. SITE NO.
copy thereof (Sec. 3800, •Lab.CJ.
Policy No. ._ Compuny
Cl Certif ted copy ishereby' furnished. .R
� 011D 9]
U. Certified p iss��t�led'',wit he city Inspection division.
Applicant" y--''rw,( 1 -
FIRE SPRINK ENERGY T-2<
'Y N Y❑' -N❑.
-
. MISC.- - REFER TO ORD.
., CERTIPICATEOF- EXEMPTION FROM WORKERS" i'.
PERMIT ISSUANCE r 6.00
FLOODZONE A.L.D.C.
PLG. CONTR. LIC. NO. PLG.-
TOTAL -
" COMPENSATION INSURANCE,
(This section need not' be completed if the'per_mil is for one
Y ❑ .IN ❑ Y ❑ 'N ❑
hundred dollars ($100) or less.).
I certify that in the performance of the work for which this per-
mit is issued,.) shall not. employ any person in any manner as as to
become subject to the Workers' Compensation Laws of California.
Dale Applicant's " - ''
t c - - -'
ON. MECHANICAL PERMIT FEE
+a ,
•- - a -
FEE SUM ARY
BUILDING '
1., ALTER OR ADD TO MECH. - "x 4.00 ..
NOTICE TO. APPLICANT: If, after making this Certificate of 8z-
-
emption,.you should become!Object IN the Workers' Compensation
APPLIANCE 4.00
PLAN CHECK
provision's of the.Labor Code, you inust forthwith comply with.
such provisions orthis permit shall be deemed revoked.''' -
'FEE
s
AIR HANDLING UNIT (TO 10pODC.F.N .'
3.00
AIR HANDLING UNIT IOV ,F-
"SEISMIC FEE
" - t
" ('..AGLNCY. ,.-
CONSTRUCTION LENDIN
1 hereby affirm that there-is-a-eonstru/ction lending agency for
EXHAUST HOOD (WITH DUCT) * - 2.00
-
the performance of the work for which this permitfs issued (Sec.
3097, Civ.C.L I ', - 1.,
Lender's Name -
Lender's Address
MICROFILM
HEATING UNIT (TO 10 r.
'HEATING UNIT(OVER 100,000 B.T.U.P.50
ELECTRIC "+
I certify that I have read this application and stale ilia; the above
I VENTILATION FAN (SINGLE)/ 3.00
-
.information is GrGhEtq I agree ID comply with all city .a ad county
ordinances and state laws relating to building construction, and
PLUMBING
BOILER-COMP(3 H.P.6n1OO,000 B.T.U.) 4.00 '!-a -
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL o-0
hereby authorize representatives of.flus city to enter upon the
.above-mentione,I properly forinspection purposes.
(We) agree to save, indemnify and keep harmless' [he City of
MISC. = • 'REFER TO ORD:
-
Cupertino against liabilities, judgments, costs and expenses whichq
may inany.way accrue against said City,in consequence of tire
e
CONST. TAX
PERMIT ISSUANCE 3.00 3
gmnh'pg Oft is permit -7 ` = L/
MECH. CONT LICNO.
effi.
TOTAL
:
OTAL -
5
Signature of Applicant/Contra r. Date
v OFFICE COPY'; ^