C 7065 1 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
• BUILDING PROJECT IDENTIFICATION
1 �( AD(/A5V-I�D K CF�1/U/PHONE `
I '' I?;•usn .gepep,L�ICATIvON &'Tt PERMIT
ERMIT
AoOR15� {�I
r y' EYn
Cl 7065 5Q (r 7 DW L iqF / •.2 MECHANICAL
OWNERS PLAN CHECK VALIDATION
;� tyELECTRIC PERMITu, t'1FEE' -L"AME 2�f'pc/OU OTY
..Fu•r. �/ � i/ -'�
CONrRACTUHS S TLETS-SWITCHES-RECEP 5.00/1.00 &�''
NAME a
&150- c.No. LIGHTING FIXTURES 5.00/1-00 '^
LON TRACTOR'S APPLIANCES-RESIDENTIAL 4.00 �(
AOOIIE55
,
PHONE PANELS 5.00 S DATE OF APPLICATION
ARCHITECT SIGNS 600 PLAN CHECK fEE P.C.NO.
OR
ENGINEER �SIGNS TRANS. 3-
LIC.NO. PERMIT VALIDATION
ARCH.OR ENG. SPECIAL CIRCUIT 5-00
ADDRESS
ZIP TEMP.METER OR PO INS. 15.00 �
APPLICANT'S MOTORS 5 E FEE SCH. mac..
ADDRESS • �•
10.00
SERVICE CHAN yvv
EI^•
wczylp�//
'09 LICENSED CONTRACTORS DECLARATION - 9
y u U I hereby affnn that 1 an licensed under provisions of Chapter 9 j 1 DANCE DATE
z.
(e.mmencinK with Section 7000)of Division 3.1 the Business and • t BLDG. ELECT. PLG. MECH.
Ha
N i Nro(e»ions Code,unJ my licenx is in full force unJ el I'ect. �14 ,LJ-1.
z o N- License Clan Lic,Number YI I lZ�l- Lao
O mr O Date Contractor ,
_ _ h^n(.°'BUILDING PERMIT 1,
a w a OWNER-BUILDER DECLARATION %r7 ' K11r"y
u MISC.- REFER TO ORD "'Y 1'E,., . 'k "'a •
E o LL N I herchy afllnm that I am exempt Rom the Contractors Liceroe VALUATION E/FT.
104 Law for the following reason.(Sec.7031.5,Buslnessand Professions PERMIT ISSUANCE 6.00
C - -` Code.Any city or county which tequiresa permit m construct,alter,
F N Q InIpNVc,JCIIIUI611,nr rCpalr ally atrY[ImC....O.IU Ib RSeance,alw ELEC.CONTR. LIC.NO. ELEC. Q ��
sa a-D Q relpllres the applicant for such permit to IIIc a signed Statement that TOTAL v PENNNSSL�TO
A W m LL he is licensed pursuunl to the provisions ul'the Contractor's License - . .! } .S nNGLe' ' -V/L,r LL/
� z >Ps
. Law(Chupter 1)(commencing with Section 7000)of Division 3 of the ;r; f •" "''• . V' Gard[;-,
PLUMBING PERMIT.
Business and Profession Code)or LILA he is exam t themfrom and OTY. s
F m the basis I.,the alleged exemption.Any violation of Section 7031.5 + •7� " 1! " '• ' r' r'+ STORIES TYPE CONSTR.
a by any applicant fora permit subjects the upPlicant toucivil penalty . ALTER-DRAIN&VENT-WATER (EA.) 4.00 Ot L5^� /7C
four more than Ilse hundred dollars(S500).1:
❑ I,as owner ol'the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole cumpt out ion,will do the work,and the structure Is nut /
intended or otfered lin sale(Sec. 7044, Business and Prufessioos DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The CUntracnr's License Law doe not apply to an owner of
property who builds or improves thereon,and who docs such work IXTUR ES-PER TRAP 4.00 ,� spa//FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provldcd ta"Deblmpmec. / GAS-EA.SYSTEM-1 INC. OUTLETS 4.00
cents ore not intended or offcred for eek. w
If,boaveq the budding
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 euaDING uSE
builder will have the burden of proving that he did not build or int- RE INO CON PS Omer
prove for purpuseof sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑
❑ L as nwner of The properly,am exclusively contra,lug wi Th
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 s -' ASSESSORS PARCEL NO.
and Pwfcicauns Cody.I'he Contractor's License Law dues not apply
to an owner of property who builds or improves thcruun,and who LAWN SPRINKLERS-PQQVER 5(EA.) 1.00
contracts tursueh prujeetswnha contractor(s)licensed pursuant to SEWER-SANITARY-S ORM :EA.200108.00 p TRACTNO. PARCEL NO.
the Cmua,tm s License Law.
(I 'nexentptundcr Scc. ,B.&BC.lot IN, / WATER HEATE h) l\fENT 4.00 '
¢asun-
Ownu_J _ Uaw_-� WATER SYSTEM r., I::.::i 4.00 � ' __TCC DATE ACC FILE NO.
Y WORKERS'COMPENSA I'ION DECLARATION WATER TREAT E U P. 4.00
1 heaby affirm That I kava a Gen it icule of cunxm to selGinsme, .r Ino ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof ISec.3800,Lab.C.).
Policy No. Company FIRE SPRINK
O ❑ Ceuilled ropy is hcrcby lumished. ENERGY T ZI
Z Z ❑ Cerlited copy is fled with the city Inspection division. MISC.- REFER TO OR Y❑ N❑ Y ❑ No
F- � Applicant
- PERMIT ISSUANCE 6.00 n -� FLOODZONE AL.,'CL - Ct RTIFICA'I'E OP EXRMPTION FROM WORKERS'
LU >_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLD. (i3 Y❑ N❑ Y❑ N❑
CL D ._ TOTAL O
(This xctlon need mol be complete) if the Permit is for oma
Z hundred dollars(5100)or less.) - - ' ' - �;FEE SUMMARVI,i;^._.
'-) O 1 cenily that in the performance of the work(or which this per- OTY. MECHANICAL PERMIT - FEE -
H mil is issued,1 shallm manner nemploy any Verwo in any aer so as to
LL +
LL U become subject to the Workeri Compcosnion Laws of California. BUILDING
Date Applicant ALTER OR ADD TO MECH.' 4.00
>_ oai NOTICE TO APPLICANT: IL atter making this Certificate of Ex- 4.06 PLAN CHECK
F 2 enation,you should become subject to the Workers'Compensation APPLIANCE
'no"'iuns of the Labor Code, you must forthwith comply with - AIRHANDLING UNIT TO'10 QFA) 3.00 FEE
U such provisions or this permit shall be deemed revoked.
O Q
CONSTRUCTION LENDING AGENCY AIR HANDLING 7I V 10ACC.F.M.) 5.00 SEISMIC FEE Q
I hereby atlno that there is a contraction lending agency Inr / EXHAUST HOOD(WI In 2.00 0: MICROFILM
the ,CN.C.unce of the work for which this permit is issued ISec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 LS'
Lend is Na 1. / OO
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.17.50 ELECTRIC /}(Ya
Lender's Address p -_- p
I Gently that I have read this application and state that the above J VENTILATION FAN (SINGLE) 3.00 PLUMBING p Lj ��
int.'Buitiuo is correct. I agree to comply with all city and county BOILER-COMP 13 H.P.or 100,000 B.T.U.) 4.00 n
ordinances and state laws relating to building construction, and Bly,
hereby authorize representatives of this city to enter upon lite BOILER-COMP (0.,100.000 BTU)SEE FEE SCH. MECHANICAL
alsove-mentioned property for inspection purposes. REFER TO ORD.
(We) agme to save, indemnily and keep harmless the City of MISC.- CONST.TAX qq
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 ..i o1 �'
...ay in any way accrue agaii.sygalti,City in consequence of the
gr' hg of this pero;i MECH.CONT. LIC.NO. MECH.
TOTAL C TOTAL 3D�6s
V am re of kpplicantjcuntactor Wte
OFFICE COPY