4556 APPLICANT,TO FILL IN INFORMATION WITHIN RED LINES - USE BALI: POINT PEN ONLY '
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER BUILDING Es .APPLICATION & PERMIT �
- f� J J
ADOHs
�' BUILDING — ELECTRICAL—PLUMBING' ^ [[
—MECHANICAL '
OWNER" - PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
#ffS. 0gr-4D li shit/G P...L-25-2-7760Y-1
CONTRACTOR'S r -)
NAE 'II I OUTLETS-SWITCHES-RECEP 5.00/1.00 -
e, CQYII Y I
LIC.No.. 6 q7 LIGHTING FIXTURES 5.00/1.00
CONTRACTORS I t APPLIANCES-RESIDENTIAL 4.00
ACTRESS II__� ,�.11 � ?�1 �1
(a0 YY�ad�.7Pr� yP. 'PHONE3/ v27 PANELS 5.00 DATE of APPLICATION'
ARCHITECT SIGNS . 6.00 PLAN CHECK FEE P.C.NO.
OENGINEEfl A
n LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG-s' r PERMIT VALIDATION
ADDRESS � SPECIAL CIRCUIT - 5.00
zIP EMP.METER OR POLE INS. 15.00
APPLICANT �l
S MOTORS SEE FEE SCH.
ADDRESS
bDulb>°ir . fos_Ga SERVICE CHANGE 10.00
o 0 o LICENSED CONTRACTORS DECLARATION '✓O 7
¢ v w I hereby affirm that I am licensed under provisions of Chapter 9
ISSUANCE DATE
G
(commencing with Section 7000)of Division 3 of the Business and< H BLDG. ELECT. PLG. MECH.
0 z Professions Code,a i license is in full foes A ffe {� -
o.z Ino License Class Lia Numbm' �j, ( . , ❑ ❑ ❑ ❑, .
at,I-w DaleZ4t- CDN ruclor_ yf�
a x s LI^ BUILDING PERMIT
¢ ¢ a
OWNER-BUILDER RUII:DI R UECLA RA'110N
a u MISC.— REFER TO ORD .INFORMATION
st a- a-to I hereby affirm that 1 am exempt Goin the Contractor's License TION $/FT.
LL O a Law for the followm reason (S 7031 5 Burl CssHnd Pr fessous
_ ,LI g PERMIT ISSUANCE 6.00 1410
Cede.Any city sh sr rep which structur e P riot k Construct,sua I filer, !_2 0 0
¢ ¢ ¢
-improve,demolish,or repair any structure,poor to its issuance,also ELEC.CONTR. LIC.N0, ELEC. T•
ca W m LL req tares the applicant for Such permit to file a Signed statement that TOTAL - ,
nr
lie is licensed pursuant to the provisions of the Contractor's License
Hza
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe Qe_ DDTG
4 o Business and Professions Code)nr that he is exempt themfmnt and QTY. PLUMBING PERMIT FEE
¢ r$ the lasts for the alleged exemplion.Any folalion of Section 7031.5 Mo er Ino TYPE CONSTR,
n3 _
by;my applicant for a permit subjects the applicant toa civil penally' ALTER-DRAIN& VENT-WATER (EA.) 4.00 '
of not more than five hundred dollors(S500),L i
❑ h as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 O RES.UNITS
their sole compensation;will do the work,and the structure is not
intended or ffared fat sale (See. 7044, business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code: pit,Contractors License Law does nut apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 50FT.FLOOR AREA TOTAL ACREAGE
himself or through h .is own employees,provided that such improve- _
,Tallaft meets are not intended or offered for sale if,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS .4,00 ' 1-1,70or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1,00 .BUILDING use
builder will have the burden of proving Him hu did not build(it im- "RES' IND CON PB -Onmr
prove for purposcnfsaleJ. INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner ol'the property,am exclusively contracting with - ❑ ❑ ❑ ❑ ❑
licensedcontractors 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`forsuch prnlectsiwilh'a contmctoNs')licensed puHaTirl to.
the Con tractor's License Caw. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO,
-
❑ 'lam exempt order Sec.-.BARC.for this
reason WATER HEATER W/VENT 4.00
Date Owner WATER SYSTEM 4.00ACC.DATE ACC.FILE NO.
WORK IiRS'COMPIiNSA'f1ON DECLARATION WATER TREATING EQUIP, '4:00
I heieby affirm that I,have a certificate of Conscol to sell-in,are,
or a certificate of Workers'Compensation Insurance,or IT ecuificd. ZONING ENG.SITE NO.
copy thereof 1800,Lab.C.J.�s '
O Polis Compuuy 6-,1��jIMCS .
Or Certifie o py is bur by fur lshed' FIRE BPRINK ENERGY T24
Z Z ❑ (.erllfI aij'y .1 c ih the Y inspection division.
O ppp' _�-y oy-- MISC:- REFER TO ORD. Y ❑ N Y [ N❑
F rn PERMIT ISSUANCE 6.00
ir — CE TIFICATEOF 0. :MPTION PROM WORKERS' FLOODZONE A.L.U.C.
LLI > COMPENSATION INSURANCE PLO.CONTR.
d O
TIN. section need not he,ronipleted it the permit is rim one TOTAL v❑ N❑ Y ❑ N❑
Z) Z a hundred dollars(S 1001 or lest) a-
U•O 1 certify that in the performance of the work for which Ibis per- QTY. MECHANICAL PERMIT FEE FEES I UMMARY
LL H mit is issued,I shall not employ any person in any manner ui as to
OU becomesubject to the Workers'Compensation Laws of California.
Lu
d Datc Applicant BUILDING s�
} m'. NOTICE TO APPLICANT: If,after making this Certil'icute of rix- ALTER OR ADD TO MECH. 4.00
Z ungrtion,you should hecome subject to the Workers'Conytnisallnn APPLIANCE' " 4.00 PLAN CHECK
provisions of the Labor Code, you most fnrlhwith comply with
U FEE,
such provisions or this permit shall he deemed revoked: AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDfNG AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 5.00 SEISMIC FEE
- I hereby'affirm-that there Is a oTGroction lending agency 1'or EXHAUST HOOD (WITH DUCT) 2.00
the putformance of the work fur which this permit is issued(Sec. MICROFILM
3097,civ.cJ. - " HEATING UNIT (TO 100,000 B.T.U.) 4.00 -
Leader'sNddr HEATI NG UNIT 100,000 B.T.U.)7.50 -Leader',Address ELECTRIC
I cerlify t0hat l hove read this application and stat,that Dao shove VENTILATIO_N•FAN ISINGLEI- 3.00
ordinn Nes 6 ,scale J I s rel to comely with all city and comity - PLUMBING
ordinances and state laws relating comply
lith construction, and BOILER-COMP,(3 H.P.or 100,000 B.T.U.) 4.00
hereby auffiouuc representatives of this city to enter upon the
BOILER-COMP (Ovor 100,000 BTU)SEE FEE SCH. MECHANICA L�
above-mentioned property for inspection purposes.
(We) agree to save, indenmify and keep hannless'th, City of MISC. .REFER TO ORD.
Cupertino agalnst.li' 'litter, 'udgmcnis, costs and expenses which PERMIT ISSUANCE - .3.00 CONST.TAX
may any way .Icr e a ins' said City'in consequence of the
gra of this P mil MECH,CONT. LIC.NQ ' MECH.
e , `O,• TOTAL TOTAL
"I car of Applicant nNrnctor Uate. 77
\IT
. - .. s OFFICE GOPY .