12594 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FIC ION PERMIT NUMBER
BUILDING - APPLICATION & PERMIT
AUORS
L �1 BUILDING- ELECTRICAL-PLUMBING-MECHANICAL 12594
OWN ER's N
,"• NAME Lli TVECtPLAN CHECK VALIDATION
. LEtiIC�ERMIT FEE
�V PHONE J (y
CONTRACTORP'
S ,3LG l UTLETS-SWITCHES-RECEP 10.00/1.00 A I ID
."b)
A E �) r r /7
-1 - t< _L (//T�'� . LIGHTING FIXTURES 10.00/1.00 9
nonness Tons1 fJ `J�� pp LIANCES-RESIDENTIAL 4.00 ^v 9 1992
I U /`)-f,/ / IP�HONE '�%L� PANELS 10.00 DATE OF APPLICATION
ARCHITECT
on PANELS (OVER 200 AMP) 20.00 FE P.C.NO.
ENGINEER
uC.NO, _SIGNS TRANS. 3.00
ARC"
.OR ENC. PERMIT VALIUAIION
Au FTESSLIGAN SPECIAL CIRCUIT 5.00 �
zip EMP.METER OR POLE INS. 20.00
APPLICANT
sS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
o¢ i
,OR LICENSED CONTRACTORS DECLARATION
w
as
u ba I hereby affirm that 1 ant licensed under provisions of C.hapIct 9
<i ISSUANCE DATE
as (commions C with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
C 0 a LICensel Clnsso and my license is in full forty cool/ef eclC ) ❑ ❑ ❑
Numb�CC y�-
R r J Dale Conlraclor
¢a a OWNER-BUILDER DECLARATION J BUILDING PERMIT
W D MISC.- '"� E T INFORMATION
u r I hereby affirm Isal I eat exempt from the Contractors License
L
O st law for the following reason.(Sea 703 L5,Businessand Professions VALUATION S/FT.
lar Code:Any city or county which requiresa permit to construct, PERMIT IS E kA^
Z > ELEC.CONTE, LIF NO.
e Q G Improve,Demolish,or repair pry structure,prior In its issuance,also ELEC.
O u requires the applicant for such permit to file a signed statement that TOTAL
aK,8 Vse is licensed pursuant to the provisions of Die Contractor's License PERMIT TO
H Z Q Low(Chapter 9(Commencing with Section 7000)of Division 3 or the -
7 4 o Business and Professions Code)or that he is exempt Iherctront and CITY. PLUM13ING PERMIT FEE
1- IIIc basis for tire alleged exemplimm.Any violation of Section 7031.5
n ; by any applicant for a Permit subjects IIIc applicant loacivil penalty STORIES TYPE CONSTB,
of nor more than five hundred dollars(S500).): ALTER-DRAIN&VENT-WATER (EA.) 5.00
O Lowner of othe property,or my employees wilt wages ns BACK FLOW PROTECT. DEVICE 4.00 UCC.GROUP RES.UNITS
theirm
Sole compensation,will do the work,and the sl n¢lu re is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner ul'
1 • property who builds or improves thereon,and who does sues work FIXTURES-PER TRAPSO,FT.FLOOR AREA TOTAL ACREAGE
e
himself or through his own employees,provided that such improv
menls are not intended or offered for sale.I L however.the building IGAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
_ or Improvement is snit within one year of completion, the owner GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving III.(he did ,Of build or im BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
O I,as owner of the property,ant exclusively nontrading with
licensed coNradors to cunslruct the project ISec. 1044,BusinessLAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:1'he Conlmcto ',License Law docs mol apply
to an owner of property who builds in Improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
Contracts for such projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.2001t/10.00 Ilse Contractor's License Law. TRACT NO. PARCEL NO.
o tam exempt under Sec.__'RAT.C.BR this
ason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORKF.RS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5,00
I hereby affirm that I have a cerlificme ofconsenl In selbinssue.
or a certificate of Workers'Compensation Insurance,or a certified ZONING END.SITE NO.
copy thereof I Sec.3EPO,Lab.C.l.`z
0
I"oIICY No.Qf�ZS/.Ca CnnpanY-I°�p.+.uACfA //� .
❑ ertilieJ L y is hertby font het.
Z Z FIRE SPRINK ENERGY T-74
f�Certif eJ pY Jed Ity�ins dicot Aivision.
O Applicant , 1f- , au:,. MISC.- REFER TO ORD. Y N v N
c N Cl: E
R II FICA'I'Ii OI' XEMPTION PROM WOR K Ii RS' PERMIT ISSUANCE �^" FLOOD ZONE AOC ❑
W COMPIiNSM1(IN INSURANCE
PLG.CONTE. LIC.No. DLO,
d Tl his section nred mol be completed if rte permit is !or one TOTAL Y❑ N� Y 0 N
� Z hundreddolhos(SIOO) olessI y, �`
U O 1 certify that in the perfonnunce of tin work f..t which Deis PCr STV MECkIANICtIL PERMIT PEE FEE SUMMARY
LL F mil is issued,I shall not employ any person in any ata to¢r so as to
U become subject to the Workers'Compensalion Laws of California
y Date Applicant ALTER OR ADD TO MECH. U L IN
} 2 NOTICE: 'TO APPLICANT: If,after ala king this Cerlificale of E.-
F IkL
empliion youtiroshould become subject to Ise Workeri Compensation APPLIANCE ' p4�fppry�
provisions io Ise Labor Cole, you most drevoke comply with E C_gF[l
C„1 such provision or this permit stall be denneJ revoked. AIR HANDLING UNIT(TO 10,000 C.F. . .00
CONSTRUCTION LANDING AGENCY AIR HANDLING UNIT(OVER 10=111. SEI
I hereby affirm Bud then Is a conernrelion lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sea MICROFILM
3097,CN.C). HEATING UNIT(TO 100,000 B.T.U.) 6.00
Lcndcr's Na...B
LnWcr's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I Imve read Ilds application mrd stale that theabove VENTILATION FAN (SINGLE) 4.00
information is correct.1 ague to comply with all Lily cool cuunly PLUMBING
mdinanas and slate laws trialing to building construclinn, and BOILER-0OW13 H.P.or 100,000B.T.U.) 6.00
herebamOc- authorise rmaerly For ins Of this city eS enter upon Ire BOILER-COMP Mart 100,000 BTU)SEE FEE SCH. MECHANICAL
y mentioned IT forinsp of fill purposes
(We) agree to save, indemnify .,,it keep honnlcss the City of MISC.- REFER TO ORD.
Cupertino against liabilities,h.0meats, Costs and expmsses which CONST.TAX
May in y way octose agaisaid Cily in consalum¢c of Ihp PERMIT ISSUANCE 10.00
ill Of Ills Onil MECH.CONT. LIC.NO. MECH.
DTAL TOTAL
Sign lure of Applicant/Con moor Dale
OFFICE COPY