5681 `APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMITNUMBER
BUILDING . APPLICATION & PERMIT
ADDRESS
/ • BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 5681
?L
CQ1?L 1,%W •,Ile
'OWNEq" PLAN CHECK VALIDATION
NAME QTY.) ♦ �/'r F E E_CTRIC PERMIT FEE
N J1<1e '` V I PHONE ,'
CONTRACTORS E UTLETS-SWITCHES-RECEP 5.00/1.00
105f y t .✓ylG( C I ' uc.No.2- - L_ LIGHTING FIXTURES - 5.0011.00 '
CONTRACTORS 4 ,- PPLIANCES-RESIDENTIAL 4.00 `
ADDRESS C ('� -
( 11C PHONE t.r2 -rr'T PANELS 5.00 DATE OF APPLICATION
ARCIIITECi SIGN$ 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
' LIC.NO. • SIGNS TRANS- 3.00
ARCH,OR ENG. SPECIAL CIRCUIT '5.00 PERMIT VALIDATION -
ADDRESS _ -
. - ZIP TEMP.METER OR POLE INS. 15.00 -
APPLICANTS• .+ MOTORS SEE FEE SCH.
ADDREW r .
SERVICE CHANGE �/
a¢i
F,o o LICENSED CON'I'RACI'ORS DECLARATION - •, C1
a u v I hemby affirm that 1 am IicenseJ undo provisions of Chapter 9 '7�...]0 ISSUANCE D E
h Q'i mmrce
(coe ,with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
E.m i ' Professions Code and y/cense is' full forda�dF•ff�cl.L e -
z O w- License C�l tris'//'� � Lic.Numher LL // +. - - ❑ •❑ ❑ ❑
Q z f D Uafc Contractor
F� ' J
¢ Q w a OWNER-BUILDER DECLARATION BUIL'DINGERMIT
Oa" - - MISC.-- . REFER TO ORD ORMEs..O �
w 3 LL r• I hereby affirm that I am exempt I'rurn the Contractors License q ION S/FT.
. Fuoa:. Lnw fnrthe following reason. 703L5,Business send Professions .PERMIT ISSUANCE._ . . - 6.00 }f
in I Code:Any city ur county which requires a permit to construct,alter, 71�
EE Q¢p III1.NVe,demolish,Or repair any Structure.poor ID Its issuance,also ELEC.CONTR. LIC.NO. ELEC. / /
-C u rcq tyres the applicant for such permit to file a signed statement Ural TOTAL Tp
a w m he is licensed pursuant to the provisions of the Contmclor's License QQ
z ve Law(Chapter 9(commencing with Section 7000)of Urvislon 3 ofthe ,1, tr :' h e +q - O /tt S
4 0 9usorass and Prolesslons Code)or that he Is ese ill thcmfrom a d OTfV:4,..'Y rs. ,PLUMBING;PERMrT� 1�, .R.,I FEE C
¢ o the basis for(he alleged exemption.Any violation of Secl on 7031.$ - - - �STwORE TYPE CONSTR.
,s ;_' by any applicant for a permit subjects the applicant to acivil penalty ALTER-DRAIN&VENT-WATER
of not mom(Iran five hundred dollars(5500).):
❑ I,as:owner of the property,or my employees with wages as .13ACK FLOW PROTECT.DEVICE 2.00 Oce.GROUP ES.UNITS
their sole Compensation,will do the work,and the structure is not -
intended or uffcred for Sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code The Contractor's License Law does not apply to in owner of -
_ property who builds or improves thereon,and who docs such work F IXTUR ES-PER TRAP 4.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve. ,
:ic!I are nm imm�ded orvlRCreA for sale.If,however,the budding GAS'EA.SYSTEM-1INC.4 OUTLETS 4.00
ser 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 not build or ice- RES IND -CON PB Other
Prove for Propose of Salc.). INDUSTRIAL WASTE INTER.- - 20.00 ❑ ❑ ❑ ❑ -'❑
❑ 1,as owner of the property,am exclusively contracting with - -
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1.INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
• to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a conlractons)licensed pursuant to
ora Contractor's License Law, SEWER-SANITARY-STORM 'EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I um exempt under Sec.-,R&P.C.fill cels WATER HEATER W/V ENT 4.00
O,loon ..
wner Dme WATER SYSTEM " " 4.00 ACC.DATE ACD.FILE No.
WORK ERS'COMPENSA'rION DECLARATION I WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate ofconsent to self-insure. ZONING ENG.SITE NO.
o'u
certificate of Workers'Campenvtiun Insurance,or.a certifnl, -
copy thereof(Sec.3900 I,abC
. .)
, .' �'/•�/-- ( - - t -
Policy No-
O ❑ rCctlilicd copy is hcrcby lurms ed. p FIRE SPRINK ENERGY T44
Z Z Cer"In'
Copy fie ' Hh/the city inaPectiun Division. MISC.P REFER TO ORD.
Applicanf_�___R�Z��L rr^""P Y ❑ 'N❑ Y ❑ NE]
CC PERMIT ISSUANCE 6.00 FLOODZONE A.L.U.C.
LU - CER'I'IIICAI'L'PE SAIiION INS RAN WORKERS' _
W >_ COA1PIiNSA'I'ION INSURANCE PLG.CONTR. s LIC.NO. PLG.
a IT'hi, sectllin heed Ilnt be completed if tire: psnoil'is fur one' `TOTAL Y'❑ N❑' Y❑ N❑
O Z hundred dolt us($100)sir less) ' y�
O O I certify that m the performance of lire work for which this perITi' seap�xNFEE SUMMARY
I shall not em to an person in an manner so as to QTY. ' .,,.'MECHANICAL! PERMIT .)4'tSnAM
LL nfi -'sed, P Y YP' Y
V 1 ora su cc pile
pm I Lewsp�Caldbrnm BUILDING dU
OED 1ttl pileppllcam +��4-tS ca- - ' ALTER OFI ADD TO MECH. 400
} W, NO I IC-TO APPLICAN f If,aHer mak ng this Certificate of fix-'
x. .
cmpfion.you should bceumc subject to Ore Worked Compensation " APPLIANCE -. 4.00 PLAN CHECK'',
provision% of tire Labor Code, you root forthwith comply will FEE
U _ such Provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 101000GF.M.) 3.00 .
,'CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10)3000.F.M.) 5.00 SEISMIC FEE,'•
1 hereby affirm that there is'a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00 . _
the performmncc of the work for which this permit is issued(Scc. MICROFILM
3097.Civ.C.). +• HEATING UNIT(T0.100,000 B.T.U.1 4.00
Lender's Name - HEATING UNIT(OVER 100,000 B.T.U.17.50 -,ELECTRIC
Lender's Address
• I Certify�tlmi 1 have read this application and state that the above VENTILATION FAN (SINGLE) - 3.00 '
information is correct. I agree to comply with all city and county. BOILER-COMP H.P.Or 100000 BTU) 4:00 PLUMBING
oubminces and slate laws relating to building construction. and , . . . - - ,
hereby authorim representatives of this city to enter upon the BOILER-COMP(0ver 100,000 BTU)SEE F EE SCH. MECHANICAL
l ubovc-mentioned property for inspection purposes.
(We) agme 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 against Said City in conequence of the PERMIT ISSUANCE 3.00 '
granting of(IDs P nn�i� MECH.CONT. LID,NO. '. MECH, ,
.TOTAL TOTAL J/ 0' .
SiX.T.'e of ApplicantlContractor -
- OFFICE COPY' -