16069 (2) CANT TO FILL IN INFORMATION WITHIN RED LINES - I `.'BALL POINT PEN ONLY
PERMIT NUMBER
:-IILDING PROJECT IDENTIFICATION APPLICATION L^, PERMIT GOG9 ADDRESS
/�Z� ��tN3W✓ BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
• �(� C. FHDNE I I�-4.?iS T FC• ^ 41154S,•
CONTRACTOR'S UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
?P�s E.I O mE tC�-x r 'ua NO. ,a0 ILIGHTING FIXTURES 10.00/1,00
CONTRACTOR'S -Li5gp 'S}eJe.oS r kt1k, JAPPLIANCES-RESIDENTIAL 4.00
ADDRS e
,S ESG9 C 5' PRONE 9q -a PANELS 10.00 DATE OF APPLICATION
ARCHT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER
- uc.No. I00 SIGNS TRANS. 3.00
ARC"iOR ENG. SPECIAL CIRCUIT 6,0 PERMIT VALIDATION
SZ 1_16 �1` .S. eSe ZIP SIA EMP.METER OR POLE INS. 20.00
APFUCY�A S �J5$/O� SPC/w... pr fl;llx( MOTORS SEE FE P
$ E,O LSU SOI SERVICE CHANGE 20.00 w
0 C o LICENSED CONTRACTORS DECLARATION /'� Q �L>
<v U I hereby affirm that 1 am licensed under provisions of Chapter 9 Sr- 32 ISSUANCE DATE -
w ¢Htmmmencing with Section 7000)of Division 3 of the Business....
BLDG. ELECT. PLG. MECH.
o z Professions Code and my license is in full force and effect. sr-A
o -' License Class Llc.Numbe520- A3 �f
9 w F Date Contractor
a m s g1, 1p BUILDING PERMIT
¢ ¢ w ¢ OWNER-BUILDER DECLARATION INFORMATION '
oma " MISC.- REFER TO ORD
X g w vHi 1 hereby affirm that 1 am exempt from the Contractor's License
HLLoj" Law for the following reason VALUATION $/FT.
(Sec.7031.5.Business Professions PERMIT ISSUANCE ^4%99 I�I
mi ns
m � Code:Any city or county which requiresa pert tocotrud,alter,
improve,demolish,Dr repair any structure,prior to its issuance,also ELEC.CIf-fQ Ayy> II
2 ¢ p CONTR. LIC.N0. ELEC. Ie, L.LiIJ L
- c u requires the applicant for such permit to file a signed statement that TOTAL3.
PERMIT TO
A w m he is licensed pursuant to the provisions of the Contractor's License
iii
Law(Chapter 9(commencing wit 11 Section 7000)of Division 3 ofthe
- ¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE J� L-
¢ r es the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
u ;m by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of at more than five hundred dollars(5500).);
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AN EA,COND. 5.00
Cade:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
;,ti himself or through his own employees,provided that such improve• GAS-EA,SYSTEM-1 6.00 ments are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of Sale.). RES IND CON PS Other
❑, 1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 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 SEWER-SAN V-STORM EA.200ftI10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec._.B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.GATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure. ZONING or a cei-tifcate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof c 3 00, a�C�J,
Policy thereof
"�$ STI�TE% Cornp.
�^ -
❑ Certified copy is hereby furnished Yls's l'2j(.+[[.r2 rV� FIRE SPRINK ENERGY T 24
z-Z a ❑ Certified cop 5 is fled with t t c mspecbon dn'Islon. ❑ ❑ ❑ ❑
Q Applicant h� ^ 'M4nA �i MISC.- REFER TO ORD. Y N Y N
CC V --� PERMIT ISSUANCE 99-90 FLOOD ZONE A.L.U.C.
LU CERTIFICATE E EXEMPTION FROM WORKERS'
W COMPENSATION INSURANCE PLG.CONTR. LIC,N0. PLG. Z
CL O (This section need not be completed if the permit is far one TOTAL J I Y❑ N❑ Y❑ N❑
::) Z hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued,I shall not employ any person in any manner su as to
O w become subject to the W'orkeri Compensation Laws of California. BUILDING
Date Applicam ALTER OR ADD TO MECH. 5.00 COZO,
} rail NOTICE TO APPLICANT': If,after making this Certificate of E.
emption,you should become subject to the N'orkers'Compensalion APPLIANCE 5.00 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 10,:1000.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE ;
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
The 3097,performance of the work for which this permit is issued 15ec HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that I have read this application and state that But no,, VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county BOILER-COMP 13 H.P.or 100,000 B.T.U.) 6.00 PLUMBING J r
ordinances and slate laws relating to building construction. and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL 7
above-mentioned property for inspection p.,,a,. T): ID
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses whichCONST.TAX 1
may in any way accrue against said City in consequence of the
PERMIT ISSUANCE i0.88 + I
ranting of this permit. MECH.CONT. LIC.NO. MECH.
D Qr �1a TA,,QJc/E �FUh1�- 52 -10 T �•I TOTAL 2
Signat S,of Applicam /Contract., Date 1 ♦ I .
OFFICE COPY