7277 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
'BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
APPLICATION & PERMIT
mul-S N0 -
ADDRLs6 BUILDING-ELECTRICAL-PLUMBING-MECHANICALIDa� 7 q4 n 7
NAME
•.
S - $F l'• a t tt, •'J h - t afT 5 - >; PLAN CHECK VALIDATION
.ItLECTRIC'PERMIT t y EE-x,
-¢.hln'U t✓✓t UU FC d.�
CONT AcroHs
NAME UTLETS-SWITCHES-RECEP 5.00/100
LIC.NO. LIGHTING FIXTURES 5.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEE
\J _0I,
LIC.NO, SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIALCIRCUIT 5,80 PERMIT VLID TION
ADDRESS
f(fp( Sti 4.e.n. (,>,/ .SRy"nv .*,S EMP.METER OR POLE INS. 15.00 ij •,
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS f�
SERVICE CHANGE 10.00
w o O LICENSED CONTRACTORS DECLARATION
v U I hereby affirm that I an licensed under provisions of Chapter 9 ISSUANCE DATE
wGn fro nunerein,with Section 7000)of Division 3 of D¢Business and BLDG. EL PLG. MECH.
r o i Proleasiun,Code,and in,license is in full fora and effect. El 1:1 ❑
z 0 u, License ClassLia Number
o z H w Date Contractor
a y s J. BUILDING P.ERMIT:;,^,-.F:,:-„
E a, W a OWNER-BUILDER DECLARATION " 'INFORMATION-'` '1."1`
woAO MISC. REFER TO ORD
g LL y I hereby aflirm that I am exempt from the Contractor's Lwcree VALUATION S/FT.
r LL
04 Law]or the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 6.0
Code:Any elly or courdy which requires a permit to construct,alter,
R ¢ Q O unprove,demolish,or repair any structure.prim to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
0 M requires the applicant for such permit to file a signed statement that TOTq PERMIT TO
E
m a. he is licensed pursuant to the provisions.1 the Contractor's License
Law(Chapter 9(ecmrencingwith Section 7000)of Division3ofthe
a Business and Professions Code)or That he iscxengN therefrom and OTV. PLUMBING PERMIT FEE
K F o the basis for the alleged exemplion.Any violation of Section 7031.5 STORIES TYPE CONSTRt
dam _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4,00
oI nn.more that five hundred dollars($500).):
)j.� I as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
thi,sole compensation,will du 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
Property who builds m improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.ET.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
menis are not intended or offered for sale.If.however,the building GAS-EA.SVSTEM-11NC.40UTLETS 4.00
HI 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 did nut build or int- REB IND PB Glhee
prove for Purpose of salc.L INDUSTRIAL WASTE INTER'. 20.00 El ❑ El 1:1❑ I,as owner of the properly,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSOr PARCEL NO.
and Professions Code:The Contractor's License Law does riot apply
to an owner alproperty who builds or improves Ihereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects will,a contractor(O licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 am exempt undoyyySec_ B.&P.C.for this WATER HEATER W/VENT 4.00
rcmon
Ownc. i Date WATER SYSTEM 4.00 ACC.DATE ACG FILE NO.
WORK 17 RS'cOM PBNSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby aflirm that I have.certificate ofconsent to wil-insac. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
cup,thereof(Sce.3R00,Iab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRESPRINK ENERGY T-24
Z Z O Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. v N v N
0 Applicant ❑ ❑ ❑ ❑
CC h CERIIFICA 11:OF EXEMPTION FROM WORK17 RS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.UC.
LU > COWIPENSA'60N INSURANCE. PLG.CONTE. LIC.NO. PLG.
d 0 (1Iiis section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
D 2 hundred dollars IS]00)or less(
U O 1 certify that in the performance of me work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
El_ 1- mit is issued,I shall not employ any person in any manner so as to
Ow bcconm yubjc't to the Workers'Grmpun u Ian Laws of Calilornia.
u Dancj-/j.A�'-5'ApphcantCV410•�^U ALTER OR ADD TO MECH. 4.00 BUILDING
} m NO11 1 APPLICANT: If,after making this Certificate of Ex-
F ? emption,YOU should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions o(' the Labor Cade, You must dorthwith comply with FEE
a such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000CP.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a cululrnetiml lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of Ilm work for which this permit is issued(Sec. MICROFILM
3097,Civ C.IHEATING UNIT(70.100,000 B.T.U.) 4.00
Lender's Name pr ��T'�rl L� HEATING UNIT(OVER 100,000B.T.U.P.50 ELECTRIC
Lender's Addmss oC ZI A. a .Zn,
I certify That 1 have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
s ntfurnation is correct.1 agree to comply with all city and countyPLUMBING
ordinances and state laws relating to building construction, and BOILER-CON?(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city 10 enter upon lire BOILER-COMP (Over,100,000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue g'���AaaMlt�T�s id ty I consequence of the PERMIT ISSUANCE 3.00
g Jlil. `� 4--a-
/ MECH.CONT. LIC.NO. MECN.
Z a- Ls TOTAL TOTAL
'Signature of Applicant/Contractor Date o
OFFICE COPY
' ELECTRIC SERVICE NOTICE16FFICE90PY b
'•'•• ,. .1_BUILDING.INSPECTOR'S NOTICE
CITY PERTINO•. y. , •. yy.\
To
You are hereby authorized to Cbnnect electriml service for.'
Owner.or Tenbnt• i•1 . i•a ^^.'Jh'"'"r`n- "'' ' i'
At
. . .YJA . 0
•No.of Wires r ' Size of Wires Size'of,Switch
Motor COOd V0 tog e' •Phaie
Hearing Load, • •1,K.) Voltage
/ .
• , � Lighr� 110_NewService '�• _' 'Rewnnect'
•No.of Meters , Heat IRO=Three Wire' • More Servitt
Nd.of Add.Meters - •• l Pow`er•! Three Phase• Move Meler •
•
OO r •ELECTRICAL INSPECTOR ••'r••"^ '��"�