5982 APPLICANT TO FILL' IN,INFORMATION WITHIN RED LINES —.USE BALL POINT. PEN ONLY
BUILDING PROJECT I DENTI FICATION PERMIT NUMBER
aI,ILDING APPLICATION & PERMIT
ADDRESS[ t I ----: l - ! .{ I. 1 ❑J -
ZI'S�I /mac LLd N�q. _ -BUILDING,-,ELECTRICAL—PLUMBING-MECHANICAL
OWN[R's a:., - `y - PLAN CHECK VALIDATION
OTY: ELECTRIC PERMIT FEE '
CONTRACTORS
NAME
NAME OUTLETS-SWITCHES.�RECEP 5.00/1.00
LIC.No. LIGHTING FIXTURES 5.00/1.00
A
ADDRESS APPLIANCES
_ APPLIANCES-RESIDENTIAL- 4.00
PHONE PANELS 5.00 - DATE OF APPLICATION
' aRcmTecT +� SIGNS � 6:00 .
PLAN CHECK FEE P.C.NO.
ENGINEEII .
UC.NO. - SIGNS TRANS. - 3.00
ADDRESS sec. SPECIALCIRCUIT,• - 5.00 PERMIT VALIDATION
ZIP ITEMP.METER OR POLE INS. 15.00-
APPLICANT'S '
ppoasss - - . . MOTORS SEE FEE SCH.
r SERVICE CHANGE
woo "LICENSED CONTRACTORS DECLARATION '`
a i,6 I hereby affirm (flat I am licensed under provisions of Chapter 9 /1
N Q, '(commencing.with Section 7000)of Division 3 of the Business and, C ISSUANCE DATE
F w2 Professions Code,and my license is in full force and effect. If BLDG. ELECT. PLG. MECH.
oz.m o- License Class Lie.Number ❑ ❑ ❑ ❑
m F to [)ate Contractor
.
me,w u OWNI?R-BUILDER UECLARA'I'ION. " 1'' BUILDING PERMIT ..
m ;LL I- 1 hercGy affirm that I,am exempt from the Contractor's License ,MISC.— REFER TO ORD INFORMATION
u-
oj Law fertile following reason, Business and Professions VALUATION
N g . PERMIT ISSUANCE ,6.00 '� S/FT.
my Code:Any city orcounty wIliCitnquiresapemnittocunstnml,alteq D
e, a, ¢ 20 improve,demolish,or repair any structure,prior to its issuance,else ELEC.CONTE. LIG N0. ELEC. '
d w0, requires the applicant for such permit to file a signed statement that TOTAL
m he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
F z <
Low(Chapter 9(commencing with Section 7000)of Division J mole
f 4 D Business and Professions Code)or that Ira is exempt therefrom and OTY. PLUMBING PERMIT FEE
IS I- pN the basis for thealleged exemption.Any violation of Section 7031.5 STORIES TYPECONSTR.
-
a.La byanyapplicant lona pemin subjects the applicant toa civil penalty ALTER-DRAIN (EA.) (t
Of not noon than five hundred dollars($5001.): Y.af Cu
❑ 1,as owner of the property,or my employees with wages as BACKFLOW PROTECTDEVICE p01'fl 0
their sole compensation,will do the work,and the structure is not . 2.00 OCC.GROUP RES.UNITS
intended or offered for.sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 4.00 '
Code:The Contractor's License Law does not apply to an owner of
pNp,,y who hllIII,or m,prlwes Himeon,and who docs such well, FIXTURES-PER TRAP • 4{00
• • str.FT.FLDOR AREA ,TOTAL ACREAGE himself or through his own employees,provided that such improve-
mems are net intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4-(EA.) 7,Op
builder will have the burden of proving that Ile did not hulld or im- BUILDING USE
prove Jet purpose of sale.). INDUSTRIAL WASTE INTER. - RES' IND CON PS Coma,Las owner of the property,ma exclusively contrucling with 20.00 ❑ 1:1 ,
' ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00
anti Professions Code:The Contractor's License Law does not apply ASSESSORS PARCEL NO,
to an owner of properly who builds or improves Olereon,and who LAWN SPRINKLERS-OVER 5 (EAS) 1.00
contracts for such projects with a contractor(s)licensed pursuant a, '
the Contractor's License Law. - SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
• ❑ lam exempt un cr Sec. ( ,B.&P.C.for this WATER HEATER W/VENT 4.00
rcas(ul—
Owner ��'7s_ L>_qe ._ WATER SYSTEM � 4.00 ACC.DATE ACO.FILE No.
WORKF:RS'COMPENSA'IION DECLARATION WATER TREATING EQUIP. 4.00
I hereby alfmn Ihot I have u certificate of mi..Cut to lell insure,
,it certificate of Workers'Comperviatiori Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Scc.3800,Lah.C.). I
Policy N. Cempuny - -
• OC1 CcDificll copy is hereby furnished.'' IFIRE SPRINK ENERGYT2<
z Z ❑ Certified copy is filed with the city inspection division.
F O Applicant MISC.- , REFER TO ORD. Y❑ NY ❑ I No
PERMIT'ISSUANCE' 6.00
'LUN CISk'fIPICATIi OF TNSA-flON INS FROM WORKERS' •FLOODZONE A.L.U,C.
W `COMPISNSATIGN INSURANCE PLG.CUNTR. LIC.NO. ' PLG.
(This section need not be completed if the permit is for one TOTAL - Y N Y NO
Z hundred dollars($100)or It.) -
U O 1 certify that in the perl'nnnance of um work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any mannerso as to
become subject to the Workers:Compensation laws of California. p
- 0. Date ApplicantALTER OR ADD TO MECH. 4.00 BUILDING' tX
} 0 NOTICE TO APPIACAMf: If,artel making this Certif.,le of Fix-
♦— Z emption;you should become subject to the Workers'Compensation APPLIANCE 4.00 ALAN CHECK
provisions of the'Labor Code, you must forthwith comply with C„) FEE such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1Q000GF.M.) 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 d SEISMIC FEE �—
I hereby affirm that there is a construction'lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the peform rce of the work for which this permit is issued(Sec. MICROFILM'
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00 l
Lender's Name
Lenders Address HEATI NG UN IT(OV ER 100,000 B.T.U.)7.50 ELECTRIC
I certify that l have read Ibis application and state that the above VENTILATION FAN (SINGLE) 3.00
information n coraco. I agree to comply with nil city and county BOILER-COMP 13 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and stale laws relating m buildingo nster tion:and _,
above-hereby entionirc representatives of this city to enter the BOILER-COMP Over 100,D00BTU1 SEE FEE SCH. ° MECHANICAL
above-mentioned property for inspection purpoms.<.
'(We) agree to save, indemnify and keep hanaless the City of MISC.- REFER TO ORD.
Cupertino against liahilities,judgments, costs and expenses which PERMIT ISSUANCE CONST.TAX
may in any way accrue againsl,mid City in consequence of Ifle 3.00 .
gr ant... ..(his. ....L MECH.CONT. LIC.NO. MECH.
\�(' --_ _ � TOTAL TOTAL
Sigdsturc of Applicant Contra or - Date p
OFFICE COPY - '
r- 1"GZ
,r I
n
r..
i
,
1
_ r {
,j.tie
r
I
�Sr +"1
It
IP
1, r
nr I�.I .• 1 .CI tl
,F rr
}.' 1
r
� � , ___. . . if,.+ ; - ii .•-fir. �� •. , r +
,
i