5295 ` APPLICANT TO,FILL IN;,INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY.
BUILDINGPROJECT IDENTIFICATION '" - - PERMIT NumeER
TIRTIL D I N-G1 . APPLICATION &-PERMIT _ 5295
ADDRESS v- BUILDING ELECTRICAL PLUMBING y MECHANICAL "J G y
�YJ aai2v
OWNER'S [ • - v PLAN CHECK VALIDATION
NAM QT.V. EyEC�'RIC PERMIT FE
,:e*8ws'^sX S, .. •'4 a. •u> .''k. a,'k'
CONTRACTORS OUTLETS'-SWITCHES-RECEP 5.00/1.00 '
NAME
LIT.NO. -LIGHTINGFIXTURES 5.00/1,0017 .
C NTRAc*OR's PPLIANCES-RESIDENTIAL•' 4.00
ADDRESS ". I �,p4 ^^ '
{ - {p(y� PRONE '�V��S t� _JIPANELS a 5.00 �' DATE OF APPLICATION
�� w `
SIGNS 6.00 aPLAN CHECK FEE . P.C.NO.
- OR. {
NGIN
UG '.uc.No. �U 3I7� " SIGNS TRANS 300
{ ARCH.OR ENG. -• �;
SPECIAL CIRCUIT
5.00 - PERMIT VALIDATION ,
ADDRESS I
r ZIP TEMP.METER OR POLE INS. 1500 '
- aP ucANrs' ."MOTORS - SEE FEE SCH.
SERVICE CHANG - 10.00 /0 ' i
w oo LICENSLD CONTRACTORS DECLARATION A
0." YrIll
a U w I'hereby affirm that,I am-lcensed I oder pro Ismns of Chapter 9 ISSUANCE DATE
y a $i 1 ommen ing with Sectl n'70001 of Division 3 of the Business and - PAIL) BLDG.
ELECT., PLG. MECH.
r w z IP of ssb s Code y cense Is In.full to'
',yf(nTS - _
o m
LicenseAl ss` � L1' L N mberr E��E�'7/-1�` ❑ ILT ❑ ❑
9 Z r Dat'- Cot tor'
-B U B' ILDINQ PERM(
¢ ¢ w ¢ OWNER BUILDER DECLARATION .? - -
O` 1 hereb affirm [hai I am exempt'from the Contractor's License MISC.- 'REFER TO ORD INFORMAT110N
w 3 u r- yVALUATION $/FT.
LL o j Law for the followinb reasou.'(Svc:7031.5;Busine sand Profession,' �',PERMIT ISSUANCE .ifV Of UpEftl 6.00'
Code:Any city or County which requires a permit to construct,alter,
R ¢ Q Improve,demolish;or repair any SVuc[dm,prior to its IssllaOCe also ELEC.CONTR. LIC.ND.- ELEC. / /_ O
wO¢' squires the applmant for such permit to file a signed statement that TOTAL-( W PERMIT TO
E
w LL he is licensed pursuant to the provmions'of the Contractor's License ,
i Law(Chaprer 9(commenaungwith Section 7000)6fs,s
Diision'3 ofthe - ' rx�`a�'h}1L -FL EL�
¢' rBusiness and Profic.ions Code) r that he isexe ipCtherefrom and QTY:. �'•PLUMBINC`si'P-ERMITf
the basis for the alleged exemption Any violation i f5ec(ion 7031.5 t g • ' ',"' c& xr,4u[ " "Sr #r y. ..' 9• d .i,. 3r STORIES TYPE CONSTR.
dby any applicant for a permit subjects the applicant to a_civil penalty ALTER-DRAIN'&.VENT-WATER (EA.) 4.00
of not mom than five hundred dollars($501: o-
❑•- 1,as owner of the propeRypor my.employees with wagei as BACKFLOW PROTECT.DEVICE 2.00 /'' 5CC.GROUP RES.UNITS '
their sole compensation,'will do the-work,-and the structure is nob
intended or offered for'sale(Sec.:7044, Business and,Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
_ Code:The Contractor's LicenseLawdoes not apply to an owner of -
• property who builds Or Improves thereon,and who does such work FIXTURES-PER=TRAP' {' 14.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees 1 rovided that such improve-
ments amnot intended oroffered for sale:lf,however;the building "GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00 ,
or improvement is sold within one year of completion the owner- GAS-EA:SYSTEM-OVER 4(EA.) '1.00 ,RUILDwG USE
v builder will have the burden of proving that 6e'd Id not build, - RES IND CON P9 Omer
Prove COT purpose of sale.). -- : - INDUSTRIALWASTE INTER:,. 20.00
❑ I,as owner of the property,am exclusively contracting with - ❑ ❑ ❑' ❑ '❑
licensed contractors.to-'constrUTPOe project(Sec. 7044,Business - LAWN'SPRINKLERS-1 INC5 V.B. 5.00 - -' ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply-
toanowner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1"OO
contracts for such projectswith a contractors)licensed pursuant to
the Contractor's License Caw. SEWER-SANITARY-STORM EA.200ft/8.00 ,TRACT NO. PARCEL NO.,
❑ 1 am exempt undci.sre. ,BAP.C.for this `
rx. • WATER HEATER W/VENT - 4,00
reason
Owner Itiute WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
y' WORKERS'COMPENSATION DECLARATION ,'1 WATER TREATING EQUIP. "4.00 ..
1 hereby affirm that I have a certificate of consent to self-insum, -
or a certificate of Workers'Compensation Insurance,or a certified: ZONING ENG.SITE NO.
copy(hereof(Sec.3800,Lab.C.). - 1 '
Policy No. ` Company - ve;,_ v-
O ❑ Certified co yis ercby furnished. FIRE SPR INK t ENERGY T-24
z Z �. Certif 'filedwit v 'i spection division.
U 'A(fplicant MISC.= REFER TO ORD. - - v,❑ N❑ Y'❑ No
Frit - - '•PERMIT ISSUANCE - 6.00
'•� CERTIFICATEOF EXEMPTION FROM WORKERS' r '' - FLOOD ZONE A.D.D.C,
LEI > COMPENSATION INSURANCE' .• ' PLG.CONTH. LIC.NO., PLG.
rd`O (This section need not be completed If:the pemmil is for one TOTAL - Y❑ CI E] No
D Z hundred d IIu1($l0o)OrhCs.) I ,t gr 4 . +¢:,a 'k`'em'f 'F fi'y=
U O 1 certify that in the performance of the work for which this Pcr QTV • MECHANICAL PERMIT t FEE Y. FEE SUM ARV
LL {- mIl rs issued,I shall not employ any person in any manner so as to E .piy ., ,ni.,++ y, c"tt Or i a, ar "w f+ ,, ,s 44
U' become subject to the Workers'Compensation Laws of California:
ED Dale Applicant ALTER OR ADD TO,MECH: 4.00 BUILDING
} W NOTICE TO APPLICANT:.If,after making'this,Certificate of Ex- '
F Z.. mnption,you should become subject(o the Workem'Compensation JAPPLIANCE 4.00 r PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE - -
E)#
r, such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY,` AIR HANDLING UNIT(OVER 110MC.F,M) 5.00 s "' SEISMIC FEE '
1 hereby-affirm (hat there is a construction lending agency for EXHAUST HOOD(WITH DUCT) _ 2.00
.the pedbrinanco'of,the work for which this permit is issued(Sec. MICROFILM
30979 Civ.C.). - . ., ' 'HEATING UNIT(TO 100,000 B.T.U.) -4.00
Lender's Name HEATI NG UN IT(OVER 100,000 B.T.U.P.50 "
Lender's Address 1 (ELECTRIC A,41 �_�
Z` Ic.ertily that l'have read tilisapplication and state,that the above VENTILATION'FAN (SINGLE) 3.00 -
Information Is correct.1 agree to comply with all city'and countyPLUMBING,
P(
ordinances and state laws relating to building construction, and BOILER-COM3 H.P.Or100,000 B.T.U.) 4.00
hereby'authorize representatives of.this city to enter upon the
above-men(ioned property for Inspection purposes: BOILER-COMP.IOver.100,000 BTU(SEE FEE SCH. MECHANICAL
(we) agree to'save: indemnify.an 'harmless the City of MISC.- _ _ REFER TO ORD.
Cupertino against liabilities,judgme s co s and-expenses whmh CONST.TAX
mayrtf
way accrue aguinit sal Cit in consequence of the PERMIT ISSUANCE 3.00 s.�A(
gr ,s P�f�^IIA MECH.CONT '{ LIC NO. " MECH aw" ' = 69x' C +`
114
TOTAL TOTAS pplicant/Contractor Date
" ^ - OFFICE COPY