09901 APPLICANT lU FILL IN INFUNIVIA I IUN VVI I HIN HILL) LINh5 - USI: BALL POIN-1 PEN UNLY
PERMIT NUMBER
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT
xDDRENC 09901
PDDREsb
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER's !" +p.,- -a � � d -�s,,i7 PLAN CHECK VALIDATION
NAME -3009 3ao QTY i,. �' ELECTRIC PERMIT ' ' FES
Y-0 Pic SI PRONE yy
CONTRACj�g
�•� NAME L�C.iH4-7� s131L✓Cf-Q UTLETS•SWITCHES-RECEP 10.00/1.00
1 4-I- Llc.No. 9 LIGHTING FIXTURES 10.00/1.00
ONTRACTOR's PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE q 43°11 PANELS 10.00 DATE OF APPLICATION
A RrtECT PLAN CHECK FEE C.NO.
on S T C4. PANELS (OVER 200 AMP) 20.00
ENGINEER
L.C.No. SIGNS TRANS. 3.00
ADR, ENG. 5.00 PERMIT VALIDATION
ADDRESS
ss SPECIAL CIRCUIT
ZIP TEMP.METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCR.
ADDRESS
SERVICE CHANGE 20.00
w0 2 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
r ddd/r
Is U u I herehy affirm that I am licensed under provisionsof Chaplet 9 ISSUAN E DATE
Z (commencing with Section 7000)of Division 3 of the 6usinessanA
BLDG. ELECT. PLG.
z w '9' Proressiov Cod am!r license is in full forcg,A)yl YeciL n 5 ❑ ❑ ❑
x o m' License ��Claggqggg Lic.Nwnber�` l_r �7
O Dete JJJ/L I CnnUaclor
a Y f BUILDING PERMIT
/
as OWNER-BUILDIi0.DECLARATION ' INFORMATION
uao" MISC.- REFER TO ORD '
X w 1 hemby affirm (hal I am exempt ,roto the Conln¢tor's License VALUAT"i
.'
f _N j Law for the following reason.(Sec.7031.5.Business and Professiolss PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct.aIle,,
a a 4 0 improve,demolish,or repair any structure,print to its issuance,also ELEC.DONTn, LIC.NO. ELEC,
w G u requires the applicant for such permit In file a signed stalemenl that TOTAL P
X$ he Is licensed pursuant to the provisions of the Contractor's License r Law(Chapter 9(commencing with Section 7000)ol'Division3oflhe !';�:Business and Professions Code)or that he is exempt Ibercf m, and DTV. PLUMSINO PERNIIT . l.at r- the basis for the alleged exemption.Any violation orSection70115 STORIESR.by any applicant for a permit subjects the applicant lou civilpenalty ALTER-DRAIN&VENT-WATER IEA.15.00
of notmore than five hundred dollars(1500).):❑ I,as owner or the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 DCC.GROUtheir role compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 5.00
Cade:The fpm Rnclor'a License Law does not apply to an owner orproperty a6D builds or Imprves thareon,and who does such work FIXTURES-PER TRA
P 5.00 so.Fr.PLOOR CE
himseff or through his own employees,provided that such improve.
mTts am not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6,00
_• or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im' RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
❑ I,as owner of IIm property,am exclusively coNracling 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 properly who builds or Improves thereon,and who LAWN SPRINKLERS-OVER B(EA.1 -1:00
contracts for such projects with a contraclotts)licensed pursuant to
the Contractor's License Law. SEWER-SANITARVSTORM EA.20011/10.00 TRACT NO. PARCEL NO.
D I am exempt under Sec. ,B.AP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER,SYSTEM 5.00 ACC.DATE ACG FILE NO,
WORKS RS'COMPBNSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of count tD ulhinsurr• TONING ENG.SITE NO.
^so or a certificate of Workers'Compen Mtion Insurance,or a certified 1�1 fill
copy i No, Sec,3900,1-eb.C.K} ¢�S, Kill
Policy No. fompanyYdli' lit-L-J- L4L.
Q ❑ CertilioJ mPY lr hereby 6vnlshe FIRE SPRINK ENERGY T 2
Z ❑ Corti ' y ' filed with he city inspection Jivisios. ISL..- ) REFER T RD. Y ❑ N❑ Y ❑ N❑
Applicant //�rA w •Vl
~ i4 RMIT SSUANCE .'"10.00 FLOOD ZONE A.L.U.C.
- CER'1'119CA E h F WORKERS'
11J > COMPENSATION INSURANCE. PLG.CON LIC.NO. PLG.
CL O (This Section need not be completed if the points is for one TOTAL Y❑ N Y ❑ N
::) Z hundred dollars(SIOM r less.) , ':f, , '1
U O 1 ceUiry that in the performance of the work for which this per T . 1 AL PERMIT;; ' FEE FEE SUMMARY:
O1F. mill is issued,i sisal]not employ any person in any manner so as Io
W become subject to the Worken'compensation Laws of Calirmon., BUILDING
Date Applicant ALTER OR ADD TOM 5.00
N NOTICE TO APPLICANT: IL after making Ihis Certificate of lia-
Z emption,you shod)become subject to the Workers'Compensattan APPLIANCE 5.00 PLAN CHECK
provisions or the Labor Code, You must forthwith comply with FEE
t.1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNI 0 F. 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD IWI 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,CY.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
I.Enders Name HEATING UNIT(OVER 100,000 B.T.U.)9.5a ELECTRIC
_ LcnJer's Address
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
\�• ordinances and stale laws relating to building construction, and BOILER-CORP(3 H.P.Or 100,000 B.T.U.1 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEESCH. MECHANICAL
above-mentioned property for Inspection purposes.
\ (We) agree to save, indemnify and keep harmless the City or MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue galnst said City b, consequence of the PERMIT ISSUANCE 10.00 (J
grantingaf thi lrmit. MUCH.CONT. LIC.NO. MECH.
y TOTAL
s L�' TOTAL
Signature of Applicant/Contra, 1 U
k
` OFFICE COPY
j