6691 APPLICANT TO FILL IN INFORMATIONWITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
RUILDING .APPLICATION & PERMIT
ADDRESS 13�•"x
- 1VV l�\h St"�FL,OSe. wA4 BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 6691
1
OWNER'S - "PLAN CHECK VALIDATION
NAME (-,OI OTY. ELECTRIC PERMIT FEE
t UY,`.CnA�O `a.S-I-
vrlDrvE
CONTRACTOR'S
NAME ; LITLETS-SWITCHES-RECEP 5.00/1.00
20u;\hG `��J\CSS uc.No�k�ll� LIGHTING
FIXTURES 5.00/1.00
CONTRACTORS APPLIANCES`RESIDENTIAL 4.00
ADORE
v. v.n2v LA 4
SRCHI j/IM b�E qb 1 7 0( PANELS 5.00 DATE OF APPLICATION
onnCHrtECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO, SIGNS TRANS. 3.00
ARCHE OR ENG. SPECIAL CIRCUIT - 5,00 - PERMIT VALIDATION
zm TEMP.METER OR POLE INS. 15.00 n
APPLICANTS
ADDRESS MOTORS SEE FEE SCH.
1 1 I(
1'b90 �(Lk WL Q.OSG W (;`fl SERVICE CHANGE 10.00 /p 1
' 02 LICENSEDCONTRACTORS DECLARATIONl.0
¢ v u I hereby affirm that I am licensed under provisions of Chapter 9 -- ISSUA E DATE
va a vai (commencing with Section 7000)of Division 3 of the Business and B ELEC PLG. MECH.
M Professions Cod}},.a license is in full for a feet
❑ ❑ ❑
i o vt License Classyr.2_ Lic.Numher�-I�L-L--i---
oContractor-'Iqe,\ , ,fy '
¢ ¢ a
OWNER-RUILUI>R DEChARATION BUILDING PERMIT
o a u INFORMATION
La 1 hereby affirm tlm[ I am exempt from the Contractor's License MISC.-, REFER TO ORD
H _ 60`� Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00 ILUATION $/FT.
Code:Any city or county which requires a permit to
construct alter, A"7f��
Q p Q Improve,demolish,or repair any structure,Nature,prior to its Issuance,also ELEC.CONTR. ^ -LIC.NO. [LEC.
- o u requires else applicant for such permit to file a signed statement that TOTAL �R I r\
E
$w he is licensed pursuant to the provisions of the Contractor's License TJ`(/�Jl/hJ
Fi > Law(Chapter 9(commencing with Section 7000)nf Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
f i o
¢ H by any
a for the alleged exemption.Any violation of Section malty STORIES TVP C NSTR.
d ; by any applicant for fivelu dreddollars S50ire 0).licam toacivil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more then five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2,00
their sole compensation,will do the work,and the structure is not OCG,GROUP RES.UNITS
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
$ Code:The Contractor's License Law dues not apply to an owner of
property who builds or improves'thereon,and who docs such work FIXTURES-PER TRAP 4.00 SO.FT.Floofl AREA TOTAL ACREAGE
himself or though Isis own employees,provided that such im
mprove-
entsamHotintendedoroffered for sale,IL however,the budding GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,.(he owner. GAS-EA.SYSTEM-OVER 4 IEA.) 1,00 BUILDING USE
builder-will have the burden of proving[hat he did not build or im. IND CON PB Omer
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑
❑ 1,as owner of [he property,am exclusively contracting with
.licensed contractors to mnst,act the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Prtifessiom Code"fire 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 projects
such pects with a conlmool(s)licensed pursuant m
the Cons moor's h roLaw. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ [am exempt under Sea ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Dale WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKF.RS'COMPENSA'I']ON DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm elm[ I have a certificate of consent to sel6insure,
or a certificate of Workers Compensation Insarcru,or a Certified ZONING ENG.SITE NO.
copy thereof(Sec,3800,Lab.C,). W e%TC Ii
Policy No."_AS•s��,'B .'L4 vtrte,—I�
0 O Ccrtifscdcopylsl'erebyfurnisicd. city 7---�— FIRESPRINK ENERGY T-24
z Z A Certified cop is filed will, the city inspection division.
� O Applicant.__p-.00.�yg�_�-�wsL -1 %aT MISC.- REFER TO ORD. Y❑ IN E] v ❑ N❑
CC vi PERMIT ISSUANCE 6.00 CIiRTIFIC 0 EXEMPTION FROM WORKERS' FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL Z (I section need not be Completed if the permit is for one TOTAL Y❑ N❑ Y❑ No
hundred dollars fS 100)ar less.)
0 O 1 Certify that in the Performance of the work for which this per. OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL F mil is issued,i shall not employ any person in any manner an as to
0 W become subject to the Workers'Compensation laws of California. r9 s,�\
LU Dale Applicant ALTER OR ADD TO MECH. 4.00 BUILDING OY U
} W NOTICE TO APPLICANT: If,after making[his Certificate of lix-
? empllun,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10m0 C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 100MC.F.M.) 5.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for - EXHAUST HOOD(WITH DUCT) 2,00
the.performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I ttrlil'y that I have read this application and sloe that the above VENTILATION FAN(SING LEI 3.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP(Over 100,000 BTU)SEE FEE$CH. MECHANICAL
(We) agree m 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 accrne against said City in consequence of the PERMIT ISSUANCE 3.00
gra ling this permit. MECH,CONT. - LIC.NO. MECH.
�� fr TOTAL TOTAL O(p
Sign Nmeo Applica /Contractor )ate
OFFICE COPY