10077 APPLICANT TO FILL IN INFORMAI IUN WI 1 HIN HED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATI ON PERMIT NUMBER
9UILOING APPLICATION & PERMIT
annREs9 .
1 11.X:.11 BUILDING— ELECTRICAL-PLUMBING —MECHANICAL
OWNER'S
NMAME
PHONE NI— �,r+, r.-,tt.•.t`.r'. PLAN CHECK VAL00 IDATION
• 1`\ W�'IREOQPOTV;.• Its. LECTRIC PERYaII_ _�;,ic,TM1�.
CONTRACT
4
�— " E UTLETS-SWITCHES-RECEP 10.00!1.00
\\ ftff LIC.NG. LIGHTING FIXTURES 10.00/1.00
C DRESS 10R ' 1113"t StAPPLIANCES-RESIDENTIAL 4.00
.� PHONE PANELS 10.00 GATE OF APPLICATION
aRCNITEC
on PANELS(OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
sec.No. SIGNS TRANS. 3.00
ARCN.OP ENG.
aGDRE99 SPECIAL CIRCUIT 500 PERMIT VALIDATION
APPLICANT s ZIP EMP.METER OR POLE INS. 20.00
ADDRESS
MOTORS SEE FEE SCH.
oREss
SERVICE CHANGE 20,00
Z
/W^
°C d c+i(/1
FOO LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
u u I hereby affirm Ilial I am licensed under provisions of Chapter 9 E DATE
6 a w (cmmmomcing with Seclinn 7000)of Uivisiun 3 of the Business and ISSU NC
F O i Prufeviunv Cnd d w) nu is in full f BLDG. ELECT. PLG. MECH.
z O`r2 — License a Lic.Numb
w Delo — Contmcfor ❑ ❑ ❑
a ¢It u OWNER-BUILDER DECLARATION -BUILDI OER IT+T.,1—,T
'x v.LL Ila- 1 hereby affhor that I am exempt from the Contractor's License MISC.— REFER TO ORD ,*- INFORMATION
W u O Q Law for the following reaxon.ISec.70)1.5,BNiincloand Prof—nol9 •VALUATION g/FT.-A
m> Code:Any city or county which requires a permit loconshucl,allm, PERMIT ISSUANCE 10.00
M Q ¢0 Im"live
'demidub,Or
repair any S........C,pr nr ID Ila ILSUaIICe,elan ELEC.CON TR. LIC.NO. ELEC.
i °u real Ones the applies"'for such Permit to
file a signet statement had TOTAL
X eg an he is licensed pursuant to the Provisions of'he Conractar s Licrme FERMI jj TO
s- z< Law(Ch.ler 9 l commencing with Se'"'m7000)of Uivisimn3nf the
z O Business and profession Cole)or Ihat he is exempt iherefror"and DTV. PLUMBING PERMIT',, ;
¢ H S file basis!m the alleged exemption.Any violation of Section 7031,5 "' STORIES TYPE CONSTR.
A. by anytureppl'hi fora permit calSubl .(heappllcan(toacivil penally ALTER-DRAIN -WATER [EA.) 5,00
Of not more Than fiv<IsunJred Jullara(3500).1:
❑ future
as Owner"the
Propel'y,or my employees wills wages as BACK FLOW PROTECT.DEVICE 4.00
(heir sole compensation,will Jo the work,snJ tls<structure is not OCC.GROUP REB.UNITS
intended 0r offered for vie(Sec. 7fN4, Business and Profession DRAINS-FLOOR,ROOF,AREA,GOND. 5.00
Code The C0n'ractmr's License Law does not apply to an owner of
properly who
builds or improves thereon,and who dors such work F IXTUR ES-PER TRAP 5.00 90.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided Thal such improve.
• menti are.not intended or offered for sale.I L however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
\ or improvement is Sold within one year of completion,the owner
builder will have the burden of proving that he did not build or his. GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
Prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON pB orh.r
❑ I,as owner of the property,am exclusively contracting wish
licensed contractorsto construct the project(Sec, 7044,Business
LAWN SPRINKLERS-1 INC 5 VB800
and Pmfeuions Code:The Contractors . . .
License Law does not apply ASSESSORS PARCEL NO.
10 an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
cordillera for such projects with a cmdrac'or(s)licensed pursuant In
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.fur this
reason WATER HEATER W/VENT 6.00
Owner Dale WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORrm that I have a A7lON a cLA RATION WATER TREATING EQUIP. 5.00
I hereby affirm Ilia' I have a certificate occ oose"!loself-insure,
ore fertificate of Workers Compensallon Irish ,,,,mr.c1crtificd ZONING ENG.SITE NO,
copy the jb jdCyAp,('.L _�f;i.SYl
Policy a dMRilLoBy
0 fJ Cetli;610 py la hereby fronts led. FIRE 9FRINK ENERGY T-74
Z Z Cer'i YWW yytt��fillled`wy yly alp pectins division.
F• O -APPIu'an— g_TSi y��l �-Il_1 MISC.- REFER TO ORD. Y ❑ No . Y❑ No
K L CERI'IFI('A'fIS 01' : EMPTiON FROM WORKERS' PERMIT ISSUANCE 10.00
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. FLOOD ZONE A.L.u.c..
Q. D ('this Section need nut be completed if file permit is for one TOTAL V❑ N❑ Y❑ ry❑
V O hundred dollars IS 100)or less.)
I certify'hm in the performance of the work for which this per OTV MECHANICAL PERMIT • - ' r:EE FEE SUMMARY,,
e'f'•:1?�
UL U mil is issued.I shall not employ any person in any manner So as to vit,,hR
W become suhjeclto the Workers'Compensation Laws of California.
pp Dale Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
N NOTICE "f0 APPLICANT: IL eller making This Certificate of lix-
Z emptum,you should become subject Io the Workers'COmpenvlion APPLIANCE .00 PLAN CHECK
ocl,,ision, of U suet,provisions for this permle Labor it shall he deemedrevoked.you must rthwith comply with AIR HANDLING UNIT(TO 10 FEE
,aaoGF.M.I 4.00
CONSTRUCTION LENDING AGENCY AIRHANDUNG UNIT(OVER 10 ling SEISMIC FEE
I hereby affirm [hat there is a emnsoucfion lending agency for EXHAUST HOOD IWITH DUCT) .00
the performance of the work for which this permit is issued(Sec.
MICROFILM
3097,Civ.C,L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I terrify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• infurmaflm is correct. 1 agree to comply with all city and county PLUMBING
ordinance, and Efate laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorise roperty for in, of this city to enter upon the 801 LER-COMP(Over 100,000 BTU)SEE FEE SCH. O L7
al(We)a agree
to property for inspection purposes. MECHANICAL
(We) agree tst vvbi indemnify and keep harmless the city of MISC.- tIRIEVERT RD.Cupertino,gains[ Sccm Iles,juJgmenb, enols and expenses whichCONST.TAX
may in any way eccroe against mid City in consequence of the PERMI E 0.00gr of u This permitECH.CONT, LIC. TOTAL/c00 ' TOTAL
t reofApplicanllCanlmclnr Uate UR nnl-ro
OFFICE COPY