5442 I ARPLICANT TO FILL IN INFORMATION WITHIN REULINES'- USE�BALL POINT PEN ONLY
• BUILDING'PROJECTIDENTIFICATION PERMIT NUMBER
BURDING APPLICATION & PERMIT
ADOREss
/D23a L�1f t'/AC wPBUILDING - ELECTRICAL-PLUMBING-MECHANICAL4i/t , 5442
OWNERS •" '•, i'« ,. « - PLAN CHECK VALIDATI0
"AME 'YOa' PTV': ^ `..`ELECTRIC PE RMIT� FEE
NT ACTORSs`�i�I°
CONTRACTOR 5
NAM •y=/ OUTLETS:SWITCHES-RECEP '5.00/1.00 ,
.t.i "C.NO. 1�O9PY
LIGHTING FIXTURES 5:00/1.00 .
+ ' roNrRAcrons - -
• 'x nooness , -/ d' PPLIANCES--,RESIDENTIAL _4.00
J
!/vVAPHONE�6�•S.700 PANELS.' 5.00 . DATE OF APPLICATION
ARCHITECT. SIGNS - '' 6.00 - PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.NO. SIGNS TRANS. 3.00
ARCH.OR ENG, PERMIT VALIDATION
ADDRESS. SPECIAL CIRCUIT '5.00
« _ ZIP EMP.METEROR POLE INS. 15.00
ADDRESNrs : .MOTORS - SEE'FEE SCH.
SERVICE CHANGE 10.00 l
w o o LICENSED CONTRACTORS DECLARATION 'a -
a u G I hereby affirm that I am licensed under provisions of Chapter 9 a I U E GATE
y'Q N (commencing with Section 7000)of Division 3 of the Business and BLDG. LE PLG. MECH.
F O z Professions Cnyy,,..
dd •Ind my license Is In full I. e a d e - ❑ ❑
4 F w Date!/f.CI�CoLic,Numb
Et Direct. i •^.t'- -
Y BUILDING.PERMITi)
¢ G w OWNIiR-BUILUIiB DT.CLARA'TION '� INFORMATION,''` -,:,�'F
a o d MISC.- REFER TO ORD '
w g LL r 1 hereby cthe offillo that I am exempt from the Contractors License Y
m '�Y+q)TION _^ T.
F 7; Caw for Any
iountyng which equinec. . permit wend Professions PERMIT ISSUANCE. 6.00 O/frVJII
Code:Any city or county which structure permit IoconstmcL alter,
W 0 improve,demolish,or repair any structure,prior to its issuaneu,also ELEC.CONTR.t LIC.NO. ELEC. -
c Ie requires the applicant for such permit In file a'signed statement that TOTAL
S - PERMIT TO
A w m m he is licensed pursuant to the provisions of the Contractor's License
- Fir Law(Chapter 9(commencing with Section 7000)ofl)ivision 3 of life
a Business and Professions Code)or that he is exempt therefrom and. OTV': PLUMBING PERMIT FEE"
le 1=- 0 the basis for the alleged exemption.Any violation of Section 7031.5 STORIES ,- .TYPE CONSTR.
a3 � by any applicant for a permit subjects the applicant loacivilonally ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(S50(h.):
O 1,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 structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 . ^
Code:The Contractor's License Law does not apply to an Owner of -
propertywhohuilJsorimproveslhcrcon,and who dOl'S 911CIh Wnfk FIXTURES-PERTRAP 4.00 SO.FT.FLOORAREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-11NC.40UTLETS 4.00
menu are Hot intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 IEA) 100 BUILDING USE
builder will[have the burden of proving that h - . . .
e did not build or im- RES IND. N PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,um exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sea 7044,Business LAWN SPR INKLERS-1 INC.5 V.B. 5.00 ASSESSOFP PARCEL NO.
and Professions Code:'I'he Contractors License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
l contracts lin such projects with it contractor(s)liecosed pursuant to -
Int Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
�p lam exempt under See B.&P.C.I'or IN, WATER HEATER W/VENT 4.00
L'amn
Owoie,, Date WATER SYSTEM 4.00 . ACC.DATE ACC.FILE NO.
W R'E PE 5A to I.ARp N WATER TREATING EQUIP. 4.00
_
L�y hrfi`11f4t T"have iii cans F-Houm,c u nl'Workers'Comwnsuliol Ilnuranee,nr u c IifiMZONINGENG.SITE NO.
ccol' Sou.3800,Lub.CJ.PCompany Z) tilled'CO yrs hereby -m' FIRE SPRINK ENERGY T-24
_z 2 C op"is EI h lispeelion division. MISC.- . REFER TO ORD.
O APPlicon Y ❑ N❑ Y ❑ N❑
OC PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.O.C.
.L'- CERI'II4CCOMPE EXEMPTION PROM WORKERS'
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d Cl (This saclio. need not 'be completed it"the pemtil is far one TOTAL Y❑ 'N❑ Y❑ N❑
Z)2 Iwndred dotars(SIO()Or less.) '« - .,
'+ U O I certify mm in file performance of the work for which this Per DTV. MECHANICAL PERMIT '-FEE "F.EE SUMMARY 'y, „•
0 F toll rs issued,I shall not employ any person in any manner so is Io �O �"
ED ixcomc subjecl.lo the Workers'Compensation Laws of California.
O w• BUILDING
0.w Date APPLICANT: I ALTER OR ADD TO MECH. 4.00
} y NOTICE TO should
If,after making this rs'C tope sa Ex-
F,•2' emption,YOU should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK '
provisions of the Labor Code, you must forthwith comply with FEE '
C1.- such provisions or this permit shall be deemed revoked.,, AIR HANDLING UNIT(TO 1OPWC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 10,000C.F.M.) 5.00 SEISMIC FEE v
1 hereby affirm that there is a construction lending agency I'or EXHAUST HOOD(WITH DUCT) 2.00
the performance Of the work for which this:permit is issued(Sea MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00 -
Lender' AddiNamHEATING UNIT(OVER 100,000 B.T. 37.50
Lender's,Address - ELECTRIC,
I certify (hal I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is cornet'I agreeto comply with all city and county PLUMBING
onirumets.mid stale laws lrelating to building'construction, and BOILER-=(3 H.P.Or 100,000 B.T.U.) 4;00
hereby authorise representatives of this city to enter upon the 'BOILER-COMP.IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
u hove-mentioneJ property for inspection purposes..
- (We) agree to Save,-indemnify and keep harmless the City of MISC.- REFER TO ORD. -
Cupertino against liabilities,jud menu,tlnsIS and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in a y way xecme g Sid City in consequence f the
mnti s permil. MECH.CONT. LIC.N0. MECH. -
TOTAL - TOTAL (r/N// .
«Igaatureof i t/ on eclor, - al' 04 / '
OFFICE COPY