4947 e,,LICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LD ING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING / �j , Ij� APPLICATION & PERMIT
••( ADDRESS t 0010 i or- Aw-- I BJ� ✓. 4947
rJ,�AT BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
`l OWNER'S1�•t�•y� �yy G ps� ccC COP-P.` NAME FIEFO �ZAL F--AI!"I1lJ Lfl�• QT ELECTRIC PERMIT FEE PLAN CHECK VA❑oATIOry
DNF y/
CONTRACTORS
NAMEpmb
UTLETS-SWITCHES-RECEP 5.00/1.00
ES // LIC.NO ZrZSI-? ILIGHTING FIXTURES 6.00/1.00 ,Ann _ E7 ��pA
CONTRACTOR'S - Nell p 84
/{
ADDRESS 51V007i APPLIANCES-RESIDENTIAL 4.00
II00•�•y3 zB��/D'�AHorvr��,�' /� - PANELS 5.00 r N
ARCHITECT - PL H P.C.NO.
�. , PaGGU�W DSLFy B^ I SIGNS 6.00
JOHrS k3ALGI X LIC NO.C-Zl SIGNS TRANS. 3.00
ADDRESS
CHx FOR ENG.n2-7•^ (3RA?VM I-J 5)F SPECIAL CIRCUIT 5,00 PERMIT VALIDATIpN
•//C/� 1`200 1AIIJ C15 60 CA zIP94Iu EMP.METER OR POLE INS. 15.00 44/15�/7///APPLICANTSMOTORS SEE FEE SCH.
Auo IC ss
SERVICE CHANGE 10.00
o ¢ i
Foo LICENSED CONTRACTORS Df°CLARAfION
Q U w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y (,.I mein,with Section 7000)of Division 3 of the Business oust
Z A BLD E ECT. PLG. CH
F N i Professions Cod• and my license is N full force and effect ❑
z0 License Class.45-/ Lic.Number��SZ3/
E�L'omractor.
H j
a m BUILDING PER
¢ ¢ w a OWNER-BUILDER DECLARATION _.
O u v INFORMATION
w ; ¢N I hereby affirm that I am exempt from the Conmminr's License MISC.- REFER TO ORD VALUATION SIFT.
LL o vs Law for the following meason.(Sec.7031.5,Businessand Professions 6.00
H - PERMIT ISSUANCE �D 000
Iw Yf Code:Any city or county which requires permit to amslnmLalrtq
fe ¢ ¢ O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTH. LIC.NO. ELEC.
O M requires the applicant for such permit to file a signet)statement that TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License
HZQ
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthc /
4 o Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE I'UTi n�es�od��-•
¢ r $ the basis for time alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant m v civil penalty ALTER-DRAIN -WATER (EA.) 4.00
Of Rot more than five hundred dollars($5001.):
❑ 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 st rocttne is not
intended or offered for sale (Sea 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Cade: 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 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself re through his own employees,or Provided ho that such improve-
ments Bre through his owoff emplo ees,sale.If, that suhemprve-ing GAS-EA.SYSTEM-1INC.4OUTLETS 4.00
or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he Aid not build or an.. RES IND CON PB Omar
prove for purpose of sale.). INDUSTRIAL WASTE INTER.
❑ I,as owner n(the property,am exdusivdy comnmting with 20.00 ID Q ❑ ❑
licensed contractors to am,Tua the Pricer(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 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 IEA.) 1.00
contracts for.such projects with a cnmructons)licensed porta unt to
the Contractors Urease Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt rider Sec. B.&IIC.kn this WATER HEATER W/VENT 4.00
reason
Date Owver WATER SYSTEM 4.00 Acc.DATE ACC.FILE NO,
WORKERS'COMPENSAIION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING
Or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE N0.
copy thereof f see.3800,Lab.C.).
Policy N.. Company
O ❑ CcNilied copy is hereby furnished FIRE SPRINK ENERGY T 24
Z- Certified cop is ��itll tate -inion division. MISC.- REFER TO ORD. y� N� v ❑ N�
O APPlicam
FNs PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
Lu GIiRI'l l'ICCOM F I A{ION'INS FROM WORKERS'
CL C.1 Get be Com INSURANCE PLG.CONTR. LIC.NO. PLGCL 0 . Y❑ N Y ❑ NEJ
nfres Dollars tied n.. be completed if the Permit in for am. TOTAL
hundred Dollars IS 1001 nr Ices]
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- emit is issued.I shall not employ an,person in any manner Do as tg
U Become subject to the Workers'Compensation Laws of Calilorniu.
U a Date Applicant ALTER OR ADD TO MECH. 4.00 Q6 BUILDING �"/o �
} N NOTICE '1'0 APPLICANT': If,after making this Cerrificutr of lis-
2 emption,you Should became subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with V-' FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10,000C.F.fA) 3.00 3
CONS'rbi OC I'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE / SrCO
I hereby affirm that there is u construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the perorium a at the work for which this Permit is issued(Sac MICROFILM
3097,Civ.CU. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lenders Name:
Lender's Address HEATI NG UNIT(OV ER 100,000 B.T.U.)7.50 ELECTRIC
1 eertily that i hour read thisapplicatim and state 1hul the above VENTILATION FAN (SINGLE) 3.00
information n colat l I agate ti comply with all city and crm(y PLUMBING
ordinances and orocc laws relating Io building conurctiun, and BOILER-COMPI3 H.P,Or 100,0008.T.U.) 4.00
hereby anhorue reptesenlatives of this city t0 enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL a
grove-mentioned property for inspection purposes.
(We) agree to Save, indemnify and keep hnonless the City'01' MISC.- REFER TO ORD.
Cupertino against lab I ,judgment costs and apenses which U CONST.TAX
may m�J y aci•�JAdgin/p��i fence of the
PERMIT ISSUANCE 3.00
EX
' hts perm 1. �l MECH.CONT. LIC.N0. MECH.
y L 8� TOTAL/ - TOTAL i qU
�; Ignahve Ol'Appicanl(Contractor Date
OFFICE COPY