17832 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY'
PERMIT NUMBER
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT
BUILDINGADDRESS I /-.� 2A /A / ^ 17832
ADDRESS � L-L� 1 H
2 _7 0gpeSICK CIS UILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S t-1FA A y)IL
QTY ELECTRIC PERMIT FEE PLAN CHECK VALIDATION
PHONE J•
Nr,ME VIII- -f _ ' �i5
NAME �RACTo )d �p O
UTLETS-SWITCHES-RECEP 10.00/1.00
�.�/ LIGHTING FIXTURES. 10.00/1.00
CONTRACTDfV'SI)/ /, yH, APPLIANCES-RESIDENTIAL 4.00
ADD Ess �C�X // /A �y
PHONE y - PANELS tO.D0 DATE OF APPLICATION
AFC ECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE pc._NO.
on
ENGINEER
LIC No. SIGNS TRANS. 3.00
ARCH OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00 n
ZIP EMP. METER OR POLE INS. 20.00 ^/ ( L/
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 '
oo LICENSED CONTRACTORS DECLARATION -� �� V661
< u w 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
y (commeneing with Section 7000)of Division 3 of the Busintss anA .• - r BLDG. ELECT. PLG. MECH.
F N r Professions Code,and my license is in full fume and effect.- A..,
z o w - License Class Lic.Number C� Of r �C
D m D
H ate Contractor
sfs - 110?/f10p BUILDING PERMIT
¢ 'e ¢ < OWNER-BUILDER DECLARATION
w u - INFORMATION
K
3 a- y 'I hereby affum that I am exempt from the Contractor's Licensc MISC.- REFER TO ORD
VALUATION S/FT.
H r. o¢ Lawtor the following rcason.ISec.]031.5,Busincoand Professions PERMIT ISSUANC 10.00
i Code:Any city or county which r,uiresa permit to eonstrueL alter,
x2 ¢ improve.demolish,or repair any structure.prior to its issuance,alio ELEC.CONTR. LIC.NO, ELEC. Q�
is K D ¢ fesf Lures the applicant for such perno,In file a flgned Slatedmin that TOTAL PERMIT TO
w 9 he is licensed pursuant to the provisions of the Contractor's License
r z i Law(Chapter 9(commencing with Section 7000)of Division 3 of the
¢ Business and Professions Code)or[lint Im is exempt(h,mf onl and DTV. PLUMBING PERMIT FEE L]
¢ r 0 the basis for the alleged exemption.Any violation of Section 7031.$ STORIES TYPE CONSTR.
aF, by any applicant for a permit subjects the applicant toes civil penalty ALTER-DRAIN IEA) 500
four more titan gLTER- . .
an live Inedhed dollars(5500).): V-�
❑ 1,as owner of the property,or my employees with wages:s BACK F LOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not _
inten nded or offered for sale (Sec. 7044.'Ilusinuss and Profession, DRAINS-FLOOR,ROOF,AREA,COND. 5.00 V/-� -
Code:The Contractor's License Law donot apply to an owner o1' f _
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 - So.FT FLOOR AREA Tor AL ACREAGE
S hinmsell or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INCA OUTLETS 6.00 Ltf��J K
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 (EA) 200
builder will have - . - . .
intve the burden of proving that he did Not build or - - BUILDING USE
Prove for purpose of sale.). INDUSTRIAL WASTE.INTER. 30.00 RES IND IND CON PB other
❑ 1.as owner of the properly,am exclusively contracting with .LJ El 0 El El
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code The Contractor's License Low docs nm apply
to an owner of property who builds or improves thereon,and who ILAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a cmurctorfs)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's orsaa License Law.
❑ Ianlexemptunder Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM - 5.00 ACC.DATE ACC.FILE NO.
WORKIiRS'COMPENSA'TION DECLARATION WATER TREATING EQUIP. 5.00 or
I hereby uIfum that I have a certiliciie cf eemsent IL self-inourc. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copyWIC
00,LI .C.1.
PoliC r� y
O ❑ �y furnished. FIRE SPRINK ENERGY T-24
z-Z ❑ Ir W,J w the hy' inspection division.
OtbpMISC- REFER TO ORD. _ Y[] NEI Y NE]
W 'E UP E.h 'I ORK PERMIT ISSUANCE - 10.00 I2 FLOOD ZONE A.L.u.c.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.' Aq D Y N Y N
CL = Il'his secl ion cud nut be completed if the permit is for one TOTAL `("1
bandied dollars IS 100)or less.)
U O 1 certify that in the Perforunce of the work for which this Per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H oul.is issued,1 shall not employ any person in any mmnner so as to
0w become subject to the Workers'Compensation laws of California.
a Did,-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING : I'1!V_
} rn co
NOTICE '1'O APPLICANT: Ili after making this Ccnificute of Ex- �•'rf/
2 emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
C..) such Provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONSTRUCTION L17NDING AGENCY AIR HANDLING UNIT(OVER 10,000CF.M.) 6.00 SEISMIC FEE g
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO100,000 B.T.U.) 8.00
Lender's No HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lcndcr:Address ELECTRIC
Icertify that l havercad this application and state that the above VENTILATION FAN (SINGLE) 4.00
infonuation is correct. I agree to comply with sell city and county PLUMBING c�
ordinances and state laws relating to building ccustruction, and BOILER-COMPOH.P.or 100,000B.T.U.) 6.00
hereby authorize repremotahves of this city m enter upsm the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL 49
above-lnmllioned property lot inspection purposes. -
(We) agree to ez/indemnify and keep harmless the City'of
MISC.- REFER TO ORD.
Cupertino ,gest liahlhlics,jud au:oIs, costs and expanses which PERMIT ISSUANCE 1000 CONST.TAX
Guy
4,cy -pent
ccrc s id City th con u a o the I�mnliiL MECH.CONT. LIC.NO. MECH.
TOTAL TOTALnt nntractor Del 49
OFFICE COPY