6048 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
AooRess
B 68
O f�
UILDING -ELECTRICAL-PLUMBING-MECHANICAL PVA 4
V{
OWNER'S - S
• NAME U.7�-crL TV -CT"i��� O(= yp l Tk i' 'r Ey ,` 'iyn" 7i q dl PLPN CHECK VALIDATION
�t DTV.: LECTRIC PERMITY ;FE e<
C, u'l- J �/r/ QJ :^ PRONE I•4.�12*,1,1 3' (: ik /4]�i
CONTRACTORS OUTLETS-SWITCHES-RECEP 5.00/100
r?C LIC.NO. Z��j. LIGHTING FIXTURES 5.00I7.00
f,ONTRACTOR2
ADDRESS
(/'�l-y� APPLIANCES-RESIDENTIAL 4.0
7 "• 1 I JC I PHONE 77�-j��L• PANELS 5.00 DATE OF APPLICATION
AnCHITECT SIGNS B.00 PLAN CHECK FEE PC.NO.
ENGINEER^�
I/cr 7 1�- CS Lm,NO,CC/.��.9-� SIGNS TRANS. 3.00
ARCH,OR ENG.
ADDRESS /� n G SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
15-1 5 ZIP 1`r/ EMP. METER OR POLE INS. 15.00
APPLICANT'S (�
ADDRESS MOTORS SEE FEE SCH. ,
Diaz ?4�- Lam.b-9 , C,-i- ))6,7e1-•-- SERVICE CHANGE 10.00 9/v
t /_�
r o o LICENSED CONTRACTORS DECLARATION C/
a u o I hereby affirm that 1 am licensed under provisions of Chapter 9
ISSUANCE DATE
Nam Icommencing with Section 7000)of Division 3 of the Bull..ss and BLDG. ELECT. PLG. MECH.
t- w z Professions CodC and my license is in full force and effect' �� ❑ ❑ ❑ ❑
Liceve C ass Lic.Number �1_Y,f
S in r Date Contractor rrjV,-r r'.s.-5r'-
¢ w a OWNER-BUILDER DECLARATION - `s `''Fti'BUICDINO,PERMIT
°AU MISC.- REFER TO ORDINF.ORMATION
X ; ¢ h I hereby affirm that 1 l m exempt from the Contractor's License -
LLOR Law forthe following reason.(Sec.7031.5,Business and Professions / VALUATION S/FT.
- PERMIT ISSUANCE 6.00 P
a, Code:Any mulish coon pair any reqStru torees a permit it o construct,,alter, .MSE
¢ re ¢ o improve,demolish,Or repair any s[rveture,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC. /�u u r'
¢ requires the applicant for such permit to file a signed statement that TOTAL
O
e w er rc he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
r z i
Law(Chapter 9(commencing with Section 7000)of Division3otthe --a "•.' a rt: 42' 7 +' r i a
f 4 a Business and Professions Code)or that he is exempt therefrom and 43Mj +.e .tPLUMBING PERMIT V74 ht'+EE{1
¢r m the basis for tirealleged exemption.Any violation of Section 7031.5 _v'aa -E:; II_hN:`.nx's STORIES TYPE CONSTR.
e. by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) q,QQ ll. 6MNdr•e�)
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2,00 OCC,GROUP RES.UNITS
their Sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4,00
Code:The Contractor's License Law does not apply to an owner of CRY I f Cupertino
• property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SQ 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-I1NC.4OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden 01 proving that he did not build or im- RES IND CON PB Omer
prove 1,as ownerose
of sale.). INDUSTRIAL WASTE INTER. 20,00
❑ d a owner of the property,he exclusively contracting with
licensed contractors to construct the project(Sec.does Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
0 El 13
and Professions Code:The Contractor's License Law does not apply
to tr owner of property who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a commctoKs)licensed pursuant to
themcLicense Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
la
❑ lam exempt under Sec. ,B.&P.C.for this
reason WATER HEATER W/VENT 4,00
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z 2 ❑ Certified copy is Ned-with the city inspection division. �
FO Applicant MISC.- REFER TO ORD. Y NY N[
it' CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 8.00 FLOOD ZONE A.L.UX.
JU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d O (This section need not be completed if the permit is for one 1TOTAL Y N� Y❑ NO
UZO hundred dollars($100)or less Togs . I � - yrry z , tg �,_
I certifythan in the erformanc of nhe wool which this er
t p CITY,�$x, x14. MECHANICAL'PERMIT�� 4a°' F 6t
Id. F mi[is Issued.1 shall not em t'at'ty-person In an •tanner so as m M 3`y� y, y
l' W become sub)ec [D the Wnj� W uv5pesi5otiolrlr ars alifOr la. ' .•Y':�" •^ -`�•-.k, F^ Y..- .1jfi".
CL Date App1' t " i ALTER OR ADD TO MECH. 4.00 BUILDING
} so NOTIC T APPLICANT` 1 :Ifl- making thls Cerbliwtc of Ex-
F-. ? emption,you should became subject to the Wnrkess'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with U FEE such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10)=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,OM C.F.M.) 5.00 SEISMIC FEE � OS
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.P.50
Lenders Address ELECTRIC
• 1 certify tlet I have read this application and sloe that the above VENTILATION FAN (SINGLE) 3.00
11110rnmtion is correct. I agree to comply with all city and county BOILER-COMP13 H.P.Or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws retailing to building construction, and
hereby authorize representatives of this city to enter upon the
ov,,-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
ob
(We •ree to save, m4mnify and keep harmless the City of Misc.- REFER TO ORD.
C Crtinol .ilist liabilities,j •nte, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
m' 'wuY + me d Inst sa City in canseyuence of the
•ran' Bol[hi permit MECH.CONT. LIC.NO. MECH.
�� TOTAL �vPV' 'f+'.w >S
TOTAL ^J
SI n�atureol'AppliunljContructor
OFFICE COPY