10282 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY #as'S9
BU LDING PROJECT I DENTI FICPERMIT NUMBER
aDn. ISL APPLICATION & PE IT O
ADDRESS
zw BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
282
OWNERS
NAME
S TV. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION
/.Z/�✓•CivaN
CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
ooe[Ss TORS �f PPLIANCES-RESIDENTIAL 4.00
/ ! PHONE `�S PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMPI 20.00
ENGINEER
LIC,No. SIGNSTRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zip ITEMP.METER OR POLE INS. 20.00 PAID
ADDRESS Ts MOTORS SEE FEE SCH.
;/-. is . 9. ,fj/ SERVICE CHANGE 20.00 . DEC 31.1985
woo LICENSED CONTRACTORS DECLA TION TEMP.POLE 30.00
U w I hereby affirm that 1 am licensed under provisions of Chapter 9 CI ufBC
in (commencing with Section 7000)of Invision 3 of the Business and BLDG. ELECT. PLG. MELH.
R w i Professions Coit d nsy license is in full force and effect. ❑ ❑ ❑
i O o - License Class__Lic.Number_/eT/,S.�f`
9 w u, w Date
Contractor a!�t71+>'.PN{Se BUILDING PERMIT
Qys
¢ ¢ w a ON'N Ii ROUILDER DECLARATION RATION
o A O INFORMATION
w ; w I hereby oRinn 0rnl I um exempt Gam the Contractor's License MISC.- REFER TO ORD
u O j Law for the followin reason.(Sec.7031.5,Business and Professions VALUATION f/FT.
- g PERMIT ISSUANCE 10.00
Code Any molishor coo my which structurepermit toconsuance,also
¢ iL ¢cr improv demolish,or repair any structure,prior t0 its issuance,also ELEC.CONTE. LIC.NO. ELEC.
O¢ rcrui license
1 �applicant for such permit to file a signed s It's Li that OTAL
u'w m w he is license ursuam to the provisions of the Contr Inr'x License PERMIT TO
Hi> Law(Chapter. commencing with Secl ion 7000)of rvsion3ofthe
Bminess and Pro ssions Code)or mut he is exe m therefrom and DTV. UMBING PERMIT FEE
¢ I m the basis for the aIle d exemption.Any violaf ol'Section 703 LS STORI TVP CONSTR.
La by any applicant for a •rmit subjects the a cant sox civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hu d dollars($5 )J:
❑ Las owner of the trey.or employees with as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their ache compensation,will th ork,and the structurere I,rs not
intended or offered for sale (Se 044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:'I'he Contractor's Licens a ocs not apply to an ownerof
properly who builds nr impr es the, ,and who docs such work < FIXTURES-PER TRAP 5.00 sa.Fr.FLoaR AREA TOTAL ACREAGE
• himscll'or through his ow mployees,p vided that such improve-
ments are not intended offered for sale. ' however,the building GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement is sol ithin one year of co lesion,the owner-
builder will have th urden of proving that he 'd not build of im- GAS-EA.SYSTEM-OVER 4 (EA.1 2.00 BUILDING USE
prove for purpose sale.). RES INO CON PB Other
❑ I,as ow of the property,am exclusively c Ir,¢ting with INDUSTRIAL WASTE INTER. 30.00
licensed cc actors to construct the project(Sec. 7 Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Proficient as Code:The Contractor's License Law docs apply
to an owner of properly who builds or improves thereon,an ho LAWN SPRI S-OVER 5 (EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law, SEWER ANITARY- ORMEA.2001t/10.00 TRACT NO. PARCEL NO.
on
❑ l am exempt under Sec. ,R.&P.C.for this / WATER HEA HE 6.00
Owner Date WATER SYSTEM 5.00 ,. ACC.DATE ACC.FILE NO.
WORK F RS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a certificate of consent to sell-insure.
or a certificate of workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy titer u 1(Sec 3800,Lab.C.). `
Policy N / �'otnpanY-�Q/�f�e6elL�
O ❑ Certified cop)'is hereby furnished.
Z Z 7Z& Certified copy is Il td lh the city inspection division. FIRE SPRINK ENERGY T 24
� O Applicxm �. �y.(O MISC.- REFER TO ORD, vE] NE] vE] IN[D
CC rn CERTI FICA TIS OP HX I'M PTI ON Ir ROM WORKERS' PERMIT ISSUANCE 10.00 /O- FLOOD ZONEC.
LU > COMPFNSATION INSURANCE PLG.CONTE. uC.NO. J PLG. q
CL 0 Qhis section need not he romplcted if the permit R for one iV� _ . /'Y�j TOTAL / r - Y N Y NF] e
bun o lMrs(5100)or lcnJ
U O I ttrtity 'n the performance of the Work for which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I s a eploy any person in any man ;r so as to
U be tom a Mr bject",th a N'or ompensalio n Laws ulifornia.
S.
UJ Datc Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE '10 APPLICANT': If,al0;,r.w t this Cr r crl iFiit. le of Ex-
? emption,you shoulJ bt u,Gu ffjem to the o 'Compensation APPLIANCE 5.00 PLAN CHECK
Provisions of the Labor Code, you must fotlhwith lnply with V FEE such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONS'I'RUcTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
I hereby a t at is a Coast, 'r oding agency for EXHAUST HOOD (WITH DUCT) 5.00
the perlismmnee of the wor: I this permit is issued(Sec. MICROFILM
30 .C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lendermler's s theme
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that I have read this application and state Thal the above VENTILATION FAN (SINGLE) 4.00
S i ordinances
n correct. I agree to comply with all city and county BOILER-COMP13 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
oNinanv`Ls and stole laws relating to building construction, and
hereby authorize representatives of this city to enter tmon the BOILER-COMP (Over 100.000 BTU)SEE FEE SCH.
above-mentioned property for inspection purposes. MECHANICAL
(We) agree to save, indemnify and keep harmless -le City Of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any wf 0. ay acct against said City in consequence of the PERMIT ISSUANCE 10.00
granting uenml MH.ECCONT. LIC.NO. MECH.
as /a �i ps TOTAL TOTAL
9fgrt5lurc cel Applmaot/Contractor Date
OFFICE COPY