8906 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY a47,2-,
13UI LDI NO PROJECT I DENTI FICATION - PERMIT NUMBER
e AOo =aOa p Yd` if APPLICATION & PERMIT
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 8906
owNER's PLAN CHECK VALIDATION
NAME
-_� DTV. ELECTRIC PERMIT FEE
PHONE
CONTRACTOR'S
NAME /J UTLETS-SWITCHES-RECEP 10.00/1.00
�j/7,eg���•LpLx' /S.3 LIGHTING FIXTURES 10.00/1.00
C NO.
CONTE ACTOR'S 4.00ADDREAPPLIANCES-RESIDENTIAL
Gi-e
�IA��ES .5�,j a ,f eff4 PANELS 10.00 4
PHONE PATE K APPLICATION
ARCHITECTPLANPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC,NO, SIGNS TRANS. 3.00
ARCH.OR ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS
ADDRESS 9 MOTORS SEE FEE SCH.
�^
5'C/jA•P�,$'ot7y-• s; s//•j- SERVICE CHANGE 20.00 /APR
' 02
0o LICENSEDCONTRACTO GCLARATION TEMP.POLE 30.00 yI �OOh
a u I hereby affirm Thal I am licensed under provisions of Chapter 9
I" (commencing with Section 7000)of Division 3 of the Business and P ANCE D E
w Q a BLDG: L MECH.
F N i Professions Code, rid y license is in full force and if
1 ❑
Z 0 m O License CI ss Lic.Numher
4 Datc�L ,cd7�LCoNrador.G�Ey92%Q�F�/ L'
Qyf
rc , M a OWNER-BUILDER DECLARATION BUILDING ERMIT
o a" MISC.- REFER TO ORD INFOR TION
W.w g H 1 hereby affirm that I am exempt from the Contractor's Licen
VALUATION $/FT.
r LL w j Law for the following reason.(Sec.7031,5,Ilusiness and Prof ons PERMIT ISSUANCE 10.00
Code:Any city oocomu,whichmquimsapermiHDconst t,alter,
S, ¢ improve,demolish,or repair any structure,prior to its ante,also ELEC.CONTR. LIC.NO. ELEC.
0 LL requires the applicant for Such permit to file a Signe tatemept that TOTAL
a w ce N he Is licensed pursuant to the provisions of the C tractor'v License PERMIT TO
F z <
Law(Ch. r 9(commencing with Section 70 of Division 3 of the
4 D Business an fessions Code)or that he exempt therefrom and DTV. PLUMBING PERMIT FEE
the basis for the • cd exemption.Any 'elation of Section 7031.5 STORI S Tv E CONSTR.
u 3 - by any applicant for comic subjects c applicant to a civil penalty
of not more than five IT red doll. $5001.): ALTER-DRAIN&VENT-WATER (EA.1 5.00
❑ I,as owner of the p crt or my employees with wages as BACK FLOW PROTECT.DEVICE 4,00
their sole compensation,will the work,and the strt c re is not OCC.-GROUP ES.UNITE
intended or offered for sale ei. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 5.00
Code:The Contractor's Li rise La e,not apply to an owner of /
property who buil,,or proves there and who does such work FIXTURES-PER TRAP 5.00• SYSTEM
9p, .FT.FLOOR AREA TOTAL ACREAGE himself or through It wo employees,pro ed that such improve- w
mentsmenotinten doroflered forsRc.ILn ver,thebuildmi; GAS-EA.SYSTEM-1 INC. OUTLETS 6.00
or improvement i Ili within one year of co it , he owner- GAS-EA.SV STEM-OVER 4 (EA.) 2.00
builder will hav the burden of proving that he JiJ Dol build or im- BUILDING USE
prove for per se ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ I,as n -of the property,am exclusively contracting with 0 1:1 ❑ ❑ 11
licensed con r.etors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 A 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 IEA.) 1.00
contracts for such projects with a Contractor(S)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
Ilse Contractors License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sce. ,B.&P.C.for this WATER HEATER W/VENT 6.00
owR
ner
ner Dae WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofcoroent Io self-insure,
or a certificate of Workers'Compensal)'on Insurance or a certified ZONING ENG.SITE NO.
copy thereof Mcc.3800,1ab.C.).
Policy Noe' S 01 Company
C) O Certified copy s hereby furnished
FIRE SPRINK ENERGY T-24
Z 2 Applicant
fed c is 9F_Z the c ily i peel inn division. MISC.- REFER TO ORD.
0 Applicant - LL y� q� y � ry�
CC w CERTIFICATE 015 EX17MMON FROM WORKIiRS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.C.
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL 0 fThis section need not be completed if the permit is for one �En A/ TOTAL .�(' Y❑ N V❑ NE)
him r.c dollars($I00)Or I,,M)
L=))
O Id
cervi in perfonnxnco nhhe work I'ar whirl $1'V. MECHANICAL P RMIT FEE FEE SUMMARY
11 dl is issued,I s I ryy�I employ any person In a� m so as to
O W become subject to Incthe W h ' ompe Ne" ws of California.
d Date Applican ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO API'). L almr nwk,ng t u tlficate of Ex-
2 emption,yoast(I d become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be dunned revoked. IDLING UNIT(TO 10,000C.F.M.) 4.00
ONSTRUCTION LENDING ACI: AIR HANDLING UNIT(OVER 10=11F.M.) 6.00 SEISMIC FEE
I hereby affirm re is a Ion lending agency far EXHAUST HOOD (WITH DUCT) 5.00
the performance of the 'ch this permit is issued(See. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Na H EATI NG U N IT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER'COMP I3H,P,Or100,000B.T.U.1 6.00
hereby authorise representatives c
of this city to enter upon the
above-mentioned property for insp of this
purposes. BOILER-COMP)Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep formless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX L
may in any ay accrue against sat icy in consequence of the PERMIT ISSUANCE 10.00
granting on,
permit. MECH.CONT. LIC.NO. MECH.
��p TOTAL TOTAL
Ignacure of Applican t/Contractor Date
OFFICE COPY