5200 .ARPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POIN'PEN ONLY
BUILDING PROJECT IDENTIFICATION ' - - PERMIT NUMBER
auLLGING -
I� AI DDI RESS
,C APPLICATION & PERMIT,a1 BUILDING—ELECTRICAL—PLUMBING—MECMECHANICALSZOO
OWNER'S`] q��1 ', d♦gyp
NAME ML�h YV IfI�L�� Ij'. �(vV� L�p� PLAN CHECK V@LIO�AT19�
•`—r aa�q//II LIxJrN/� DTV: ELECTRIC PERMIT FEEPHON
' .•.�Lpp U� { �j+-R
ON FACTOR /
X NAME LP-.P.•(a2d .rP� �OUTLETS-SWITCHES-RECEP 5.00I1.00' '
r'O U.f:6 uc N4',.� LIGHTING FIXTURES 5.00/1.00 . _
nooeEss TORS r5PPLIANCES-RESIDENTIAL 4.00
PRON «ar PANELS 5.00 DATE OF AP PLICATION
OR C ITEf.T ♦, SIGNS'', . 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER j
.uc.so.I I I 4cikok SIGNSTRANS. - 3.00
AooFEss ENG, SPECIAL CIRCUIT 5.00 ,PERMIT VALIDATION '
nP EMP.METER OR POLE INS. 15.00 S PAID
APPLICANT'S -
ADDRESS MOTORS SEE �,f (
. _ SERVICE CHANGE 0. 0
F'0 7/M/ty�/r({fI'D ly
�/1/Sr(C1T984
o ¢2 O LICENSED CONTRACTORS DECLARATION,
a v wN (commencing with Section 7000) f Division 3 of the Busine
I hereby affirm that I am licensed under provisions of Chapter 9 ISSDAN C A e,rtino
I—a oss and —gCDG7 ELECT. I PLG.• MECH.
r w z Professions Code, 5 my license is in full fore
and and eft
Z,o m — License Class—..pY.__f_Lic;Numbe _
� N ' ontractor
¢ M M a OWNER-BUILDER DECLARATIONBU-1-01—NG PERMIT
°' u MISC.- REFER TO ORD INFORMATION
X g_u m I hereby affirm that 1 am exempt from the Contractor's License $/FT.
"'u O¢ Law for the following mason.(See.7031.5,Business and Professions VALUATION
- PERMIT ISSUANCE 6.00
� W 3 Code:Any mulish county whiny structure,es a
prion outs issuance,
also � 73 OO/Q
¢ ¢ ¢ O improve,demolish;or repair any structure,prior to its issuance,also ELEC.GONTR. LIC.NO. ELEC. O '
wm¢ requires the applicant for such permit to file a signed statement that TOTAL a PE MIT,TO
he is licensed pursuant to the provisions of the Contractor's License -
F z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe .�
i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r m the basis for the alleged exemption.Any violation o(Scelion 7031.5 - STORIES TYPE C STR.
a 3 by any applicant for a permit subjects the applicant to civil penalty '\ r
or not more(Iran five hundred dollars(S500)J: ALTER-DRAIN Sr VENT-WATER (EA.) 4,00'
❑ I,as owner of the property,'or.my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 n,Cp' — OCC.GROUP RES.UNITS
„ their sole compensation,will do the work,and the structure is not q
intended or offered for sale(Sec. 7044;Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 j
Code:Tire Contractor's License Law does not apply to an owner of K
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 4.00
or improvement is sold within one year of completion, the owner- •'GAS-EA.SYSTEM.OVER 4(EA.) 1.00 euaplNG USE
builder will have the burden of proving that he did not build or ire- - RES cop CON PB Omer
prove for purpose of sale.). INDUSTRIALWASTE INTER. , 00 ❑ ❑ '❑ ❑ ❑
❑licensed as owner of the property,am exclusively contracting with
anPro contractors to construct the project(Sec.7044,of apply LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License s thereon,
does no d who _ -
' to an owner of property who buiMs or improves thereon,and who LAWN SPRINKLERS-OV E A. ::1, D 3 f 6 -a '��o.•Z 3
contracts for such projects with a confraclots)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STOfl .20Oft/8.00 TRACT NO. PARCEL NO.
O 1 am exempt under Sec. ,BAP.C.for this
reason WATER HEATER W/VENT CB 1 6 ,yo/
Owner - Date WATER SYSTEM 4.00
ACC.DATE - ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00 f
I hereby affirm that I have a certificate of consent to self-insum, ZONING ENG.SITE N0.
or a cerlificate of Workers'Compensation Insurance,or a certified
copy,thereof(Sec.3800,Lab.0
Policy No. Companyr
0- O Certified copyis hereby furnished. I
FIRESPRINK , ENERGY T-24
Z ¢ v ❑ CertlI��Ieit copy is fie with the city i s e ion division. MISC.- REFER TO ORD. '
App &Q Y❑ N❑ Y ❑ .N❑
~ 9_ PERMIT'ISSUANCE 6.00 FLOOD ZONE' 'A.L.U.C.
c CERTIFICATE OF'EXEMPTION FROM WORKERS'
LU > COMPENSATION INSURANCE - PLG.CONTH. LIC:NO. PLG. .� I
CIL D (This section need not be completed if the permit is for ono TOTAL K Y❑ No , Y❑ N❑'
LD Z hundred dollars IS 100)or less.)
U O. I certify that in the performance of the work for whichria per- QTK: MECHANICAL PERMIT -FEE FEE SUMMARY , Y' "km
LL h'• mit is issued,I shall not employ any person in any manner So as to
O W 'become subject to Ire Workers'Compensation Laws of California, '
Dalt—Applicant BUILDING .S 4 'I,
} W' NOTICE TO APPLICANT: If,after making this Certificate o1"Ex- ALTER OR ADD TO MECH. 4.00 . �S,_�,.
2 emption,you should become subject to the Workers'Compensation APPLIANCE - A 4.00 PLAN CHECK ,
provisions.of the Labor Code, you'must forthwith comply with FEE '
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10=C.F.M.)
• CONSTRUCTION LENDING AGENCY AIRHANDLINGUNITIOV .`5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WIT MCT)
the performance of the work for which this permit is issued(Sec. d MICROFILM -
3097,CIv.C,).; HEATING UNIT(TO 100, IJ,. 4.00
Lcpder's Name HEATING UNIT(OVER 10 ,0 OB.T_.U.)7.50 f
14
Lender's Address - ELECTRIC 1
I certify that I have read this application and state Ihnl the above VENTILATION FAN (SINGLE) 3.00 —
A information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 -
y hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Ovei 100,000 BTU)SEE FEE SCH. `MECHANICAL 6
'(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT 3.00 CONST.TAX
may in any way accrue against,said City in consequence of the i -
la mgoLthis per MECH.CONT. LIC.NO. MECH.
TOTAL , I TOTAL 9 7
i n to f p Rant/ on rac(or Date CYC/
• OFFICE COPY /
b