17198 .'APPLICANT TO FILL-IN INFORMATION^WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION .PERMIT NUMBER
BUILDING APPLICATION & PERMIT q
ADDRESS r _I
!z 1737) •� BUILDING -.ELECTRICAL-,PLUMBING -MECHANICAL ' .,,,
W 7198
on,A l - " PLAN CHECK VALIDATION
N
K, 572 OTY. - ELECTRIC PERMIT FEE
ioe; I - .
'PHONE -
NAME
CONTRACTORS L{'CJ UTLETS-SWITCHES-RECEP 10.00/1.00
NApp ` �j 16
G .AJ " LIC.No.p4; 2Q LIGHTING FIXTURES 10:00/1.00 �' Pc 3 ,I--o, f L
CONTRACTORS SvuNYYAIC- G - PPLIANCES-RESIDENTIAL 4.00 -
ADDRESSa,
9 PHON PANELS 10.00 DATE OF APPLICATION
RCHITECi r PLAN CHECK FEE P. NO.
- t PANELS (OVER 200,AMP.) 20.00 - .�,.
ENGINEER I' L10.N0. � LO SIGNS TRANS. 3.00 '
ARCH(OR ENG. - - - - PERMIT VALIDATION
ADDRESS• Y SPECIAL CIRCUIT 5.00 - ,
EMP.METER OR POLE IN 20.00 �•--�
ADDRESS � �, pAjt MOTORS SEE FEE SCH. J ll+
SERVICE CHANG 20.00
O 10- LICENSBU CON'T'RACTORS IJECLARATIONKIN
_
v G - 1 hereby uffii that 1 ann licensed andel provisions of Ch t I - ISSUANCE DATE _.
(commencing with_Section 70001 of Division 3 of the Businessand
G n BLDG. ELECT: PLG. MECH.
U V,z - Licenssiom Code, d my license is in full fYrceAn,tl gfje-. -
Z O w - License la. Con Number
4 Date Conrructor_G.� �/-
a Y BUILDING PERMIT '
a o a OWNER-WRLDER DECLARATION _
i 0 'INFORMATION
w g ,� 1 hereby affln i'dial I am exempt from the Contractor's License MISC.- REFER TO ORD
t+ - VALUATION- $(FT.'
n 04 _ Law for the following reason.(Sec.7031.5,Businessand Professions pERMIT ISSUANCE (.Z�OG x&99
Code.Any city or wanly which requireso permit to construct,alter, 'fes
to> 2 improve,demolish,or repair any structure,prloalo its issuance,also ELEC.CONTR. JC.NO. ELEC. ( � O D O
DLL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License _
Hz> Late(Chapter 9(comenneing with Section 7000)of Division 3 ofthe -
a Ilusmesa and Professions Code)or that het exempt Therefrom unci OTY. ,PLUMBING PERMIT. FEE
¢ T=- o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TVP CONSTR.
byanyapplicant fora permit subjects the upplicom loaeivilpenally gLTER-DRAIN.&VENT-WATER IEA.) 5.00
DID ot more than five hundred dollars($5001.): - -).,(z I -
❑ I,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,AREA,COND. 5.00
Code The Contractor's Llcnse Law does not apply to an owner of _
propertywho builds or improves thereon,and who docs such work FIXTURES-PER TRAP' 5.00' (� so.FT.FLOOR REA TOTAL ACREAGE
himself re Through his own employees,provide)that such improve. -
oments rimprovnotemenntendedor withinronefor
year
completion(be theobuilding GAS-EA.SVSTEM-11NC.40UTLETS 6.00 /O17
or improvement is sold within one year of completion,did car the owner. GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 l
bulWer will hove[he burden of proving that Ira did nnl huilA or on. BUILDING USE
prove for purpose ofsaleJ. RES IND - CON. PB - Onbar
❑ I,as owner of the properly,ran exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 r
' - licensed contractors to construct the project'ISec.7044,Business LAWN SPRINKLERS- 1 I 6. 0 Ess RS PARCEL NO. 1
( and"Professions Code:The Contractor's License Law cines not apply
to on owner of properly who builds or Improves thereon,and who LAWN SPRINKLERS-OV 5 A 1 _
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STD 0
the Cp ntractori License Law. - .' UR NO. 1 PARCEL NO.
❑ I and exempt under Sec. - ,B.&P.C.for Ibis WATER.HEATER W/VENT 6. 7
reason - -
Owner Dote WATER SYSTEM ,DATE ACG FILE NO.
WORKIiRS'COMPIINSATION DI!CLAItnI'1(yN�^ WATER TREATING EQUIP. 5.00
hereby affirm that Ihm7c acertifiaateofconsenl toself-insure, - ZONING
or.a certificate of Worker's Compensation Imurance,or a certified ENG.SITE NO,
copy thereof Cm Luh.C.l.��,�-��`.,^
Policy NtCpmp:my
Q ❑ Ce dIe opy is hereb fur a FIRESPRINK ENERGY T 24
HZO p�Cert it'ied o �I�y w T Ili y.in.yr ction division. MISC.- REFER TO ORD. . v N v N
w 'T ,-PERMIT ISSUANCE e� .�
-� CRRTIFICA'1'1;01'EXEMP110N PROM WORKERS' - I L. DO FLOOD ZONE A.L.U.C.
LL COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. ^J�
CL 2 (This section'need nor be comphiled if the pencil is hx'one TOTAL�s� V N� V [3 NC
hundred dollars(S 100)or lessI
I
U O 1 certify that in The performance of the work for which tliis'par OTY. MECHANICAL PERMIT - FEE FEE SUMMARY )
LL I- mit is ioued,I shall nor employ any person in any mmmner so ax to
Ow become subject to the Workers'Compensation Laws ofCallforma. ar��
n Date Applicant - ALTER OR ADD TOMECH. 5.00 LW BUILDING
} to NO"I'ICE 10 ANTICAN'1': If,after making this Certificale.of ns-
eruption,you
seruption,-you should beconm Subject to the Workers'Co.. rotation APPLIANCE 5.00 ' PLAN CHECK
provisions of Lie Labor Code, you must-forthwith comply with FEE I
U such provisions or this porntit shall be deemed revoked. AIR HANDLING UNIT(TO 10/DDC.F.M.) 4.00
CONSTRUCTION LENDING AG17NCY AIR HANDLING UNIT(OVER I0,000C.FM.) 6.00 SEISMIC FEE C3
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT)' 5.00 1 -
the performance of the work for which this permit is issued IS".
3097,Civ.0MICROFILM
' J. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
A .-A.,I - S OL�
Lender'sNameAddress HEATING UNIT(OVER 100,000 B.T.U.)9.50 )\ ELECTRIC-
Y 1 certiTy that I have read This application and state that the above VENTILATION FAN (SINGLE) 4.00 IX•5it.tiii
information is wm:et. I agree Ip comply with all city and county PL
d71VIBING ��
ordinances and state laws refiling to building construction, and BOILER-COMP H.P.or 100,000 B.T.U.) 6.00 .,tI
hereby lutlhorite representatives DI this city to corer upon the W
above-mmLLiancJ property for inspection purposes. BOILER-COMP IOver 100,000 BTU(SEE FEE SCH. MECHANICAL' L
(We) agree to save, indemnify and keep harmless the City,of- misc.- REFER TO ORD.
Cupertino against.liabilitho,judgments, costs and expenses which PERMIT ISSUANCE �� IV" - CONST.TAX -
-- -may in any way aceta against said City in consequence of the
rat"ng of this permit. MECH.-CONT. S LIC.NO.t MECH: '
A ?A11V j h TOT TOTAL
4t
u App icanl Cnntrac or Date [ '
OFFICE COPY