16968 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION -PERMIT NUMBER
BUILDING APPLICATION & PERMIT �+(� Q
AOGRESS U J U
10'37157 I-tsYIZNJI (LOA_h BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S
-- t�IS`LI(i6-35"1' _ PLAN CHECK VALIDATION
NAME
QTY. ELECTRIC PERMIT FEE
•
1�eTORs'r7AuQgdJNE CONTRACTORS'S
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00 PZ.Ub I ?
Z,&I t4e IZ LIC.No. LIGHTING FIXTURES 10.0011.00 1A • 3
CONTRACTOR'5 J /
ADDRESS APPLIANCES-RESIDENTIAL 4.00 PP5119189 33fo�
PHONE PANELS 10.00 DATE OF APPLICATION
OR
PANELS fOVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. ISIGNS TRANS. 3,00
ADDRESS ENG. S•J
SPECIAL CIRCUIT S.00 PEyRM�IT VALIDATION
I
C S 3 CrCOS 5 S PQrN G C'r 14'S7ao EMP.METER OR POLE INS. 20.00 ���
APPLICANT 77 /381-DEN �/L MOTORS SEE FEE SCH.
ADDRESS
LC S 41--05 C 4 9 4-vA 2 SERVICE CHANGE 20.00
W o o LICENSED CONTRACTORS DECLARATION
APR 11 1390
a v v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DAT
Ps a$ (commencing with Section 70001 0!Division 3 of Businesf and BLOC ,I MECH.
y z Professions Code,and my license is in full force and effect
License Class Lic,Number
3 is r w Date Contractor ^'I
4 se s 1� BUILDING PERM(
E w a OWNER-BUILDER DECLARATION s -
° O - MISC.- REFER TO ORD INFORMATION
u ; ` 1 hereby affirm that I am exempt from the Contractor's License
n w VALUATION $/FT.
u o¢ Law for the following reason.(Sec. uiresa,erminessand Professions
� PERMIT (SSU 10.00
Code:Any atyor countywhiny regmrere permiltoconsuan als. 21
T ¢ ¢Q improve,demolish,or repair any Strunur<,prior to its issuance,also ELEC.CONTR. L ELEC.
y w m u requires the applicant for such permit to file a signed statement that TOTAL L ` PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
HiQ Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe Q
4 D Business and Professions Code)or that he is exempt therefrom and QTY. PLU BIirCIFERMIT - ' FEE VI �Jltl'
IS I-$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(S500t):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 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,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 So.FT.FLOOR AREA TOTAL ACRE4GE
himself or through his own employees,provided that such improve- UJ (ipp
menti are not intended or offered for Sale.If.however.the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00 /14IQ A 4
...�•) or improvement is sold within one year of completion.the owner- G 1 L�
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
for purposeRES IND CON PS Other
Prove as owner of the.). INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
❑ d as owner of the property,he exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS 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.) 1.00
contracts for such projects with a conlracmrts)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA,200ft/10.00 TRACT NO. PARCEL NO.
❑. I am exempt under Sec,.,B,&P.C,for this
reason WATER HEATER W/VENT 6.00
-
Owner t Z Dater WATER SYSTEM 5.00
iut ACC.DATE ACC.FILE NO,
WORKF-RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure.
or a certificate of Workers'Compensation Insurance.or a certified 20NING ENG.SITE NO.
copy thereof(Sec.3800.Lab.C.).
Policy No. Company
0 - ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspersion division.
❑ N❑ Y E] NNE]I-' O Applicant MISC.- REFER TO ORD. Y
2 w CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE I.G.PCONTR. LIC.NO. PLG. a V N V N
Q. Q (This section need not be completed if the permit is for one TOTAL 41- 1� ❑ ❑ ❑ ❑
Z h undred dollars IS 100)or less.l
U O I certify that in the performance of the work for which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any manner uI as to
become Sub'ecI a Workers'V&cnsmi n L of Ca rn1 .
� y Date 7U4 Applicant LL`L--Elt Alf W&�S-�A�a/�t) ALTER OR ADD TO MECH. 5.00 BUILDING I� �
} to NOTICE TO APPLICANT: If,after making this CeniOcute OF Ex-
I- ? emption,you should become subject to the Workeri Compensation APPLIANCE 5.00 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 1Q=GF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10ACC.F.M.) 6.00 SEISMIC FEE 91
I hereby affirm that there is a construction lending agency for14
EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). caa N�2� HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC 79 I
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 gra�.
Or Information is correct. I agree to comply with all city and county BOILERPLUMBING
ordinances and stale laws relating to building construction, and -COMP H.P.Dr 100,000 B.T.U.1 6.0 0 p
hereby entioed representatives of This city to enter upon the BOILER-COMP 10var 100,000BTUISEE FEESCH. MECHANICAL 1 1 Ih
above-mentioned property for inspection Purposes. 1
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. r
Cupertino against liabilities,judgments, costs and expenses whichZ CONST.TAX 1
may in any way accrue against Said City in consequence of the PERMIT.ISSUANCE 10.00 1
granting of this permit. MECH.CONT. LIC.NO. MECH.
�.-�-+--r -+/-"-01 211 r�Q TOTAL ^ �t 9 r TOTAL �' So
Signature al Applicant/Contranor Uae / 7
OFFICE COPY