09681 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED. LINES - USE BALL-POINT PEN ONLY
.I ^BUILDING PROJECTIDENTI FI N - PERMITNUMBER
BUILk'RG APPLICATION & P IT ' 09681
ADD BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
OWN R'lePLAN CHECK VALIDATION
NAM/E�•�nDqq QTY. ELECTRIC PERMIT FEE
D CONTPHONE -pA -
NAME CTOfl3�.• ,JAId OUTTS- HES-RECEP 10.00/1.00
&Y `• C �) LC.No, Q�� LIGHTILENG FSIXTUWITCRES 10.00/1.00
/ CONTRACTOR'S
q�p(�lREss (j(IQL(II�g/9/{IE ' APPLIANCES-RESIDENTIAL 4.00�.! ✓ 41942Iil &E PHONE /, PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.N0.
OR I PANELS (OVER 200 AMP) 20.00
ENGINEEfl
yj5,A(11 LIC.NO. Q SIGNSTRANS. 3.00
ARCH.OR ENG. I PERMIT VALIDATION
j;Ess SPECIAL CIRCUIT 5.00
3DM �5T, 60eN ZIP TEMP.METER OR POLE INS. 20.00 --
APPLICANT'S t 9fbiv MOTORS SEE FEE SCH. /. ,...,, -0..•-J
ADDRESS T!/
haaralu- E. E y SERVICE CHANGE 20.00
r o o LICENSED CONTRACTORS DECLARATION - TEMP.POLE 30.00
¢ u I I herebyafRrin that I mor licensed undenprovlslousof0mocr9 ISSUANCE DATE
H a y (commencing with Section 7000)of Division 3 of the Business and BL_Dy.� LECT. PLG. ME
r m z Pro@sxinns Corlu ml my license is in full force n d effect. _ YapEY.laRp�� IV�Y�.,gBI
z z a - License CI s - Lie.Number - -
4 m tcaDail!n��[� Con Contractor -
¢ a ¢ ¢ Y OWNFR.I1UILDER DECLAR IO ., t�BUI PERMIT
o a U - IV M IN ORMATION
E
3 ¢ h 1 hereby afflrm,that I am exempt from the Contractor's License MISC.- REFER TO ORD
an u o ar Law for the following reason.(Sec.7031.5,Business and Professions I - VALUATQI 5(FT.
a Code:Any city or coumy which requiresa permit to construct,alter, PERMIT ISSUANCE 10.00 ,# CM��j�0T1I7-
¢ Q¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO: El /(/(JO.
a u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n w-$ he is licensed pursuant to the provisions of the Contractor's License
r z i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
sic Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ; by any applicant for a permit subjects the applicant too civil penally ALTER-DRAIN (EA.) )
of not Phone then five hundred dollars(S50D.):. µ'
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP REB.UNITS
their sole compensation,will do the work,and (tic structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00 I
Code:The Contractor's License Law does not apply to an owner of '
property who builds or improves thereon,and who does sac It work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself re of ughinti his own eared fors,provided that such ibuildi o-
ments not intended or employee sale.rlf,bowat sthe....o.e. GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvunhent is sold within one year of completion,the ownerIII
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.). INDUSTRIAL WASTE INTER. 30.00. . . RES ��-t�-D1CON PB Omer
❑ I,as owner of the property,am exclusively contracting wish L'1 LJ
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 VB600 ASSESSORSPARCEL NO.
El
and Professions Code:The Contractor's License Law does not apply t
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 3 G 6 ra'--•Q�
contracts for such projects with a contractor(s)licensed pursuant to - `s'1;✓
the Contractor's License Law. - SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. 1,HAP.C.for this WATER HEATER W/VENT 6.00 O
sort
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to s,Ilainsur,.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
Copy Ibereof(Sec.3800,Lab.CJ.
Policy No. Crilnpun
` ❑ Ccrlifie y mmsl
z Z. ❑ _rem' n.eDpy il• coil 1 1 i et ran dlVlilOn., FIRE SPRINK ENERGY T44
F O icant - MISC.- REFER TO ORD. Y N❑ Y ❑ No
LU 'I'E 1'SXEAI.N ' OM' 00
IiRS' PERMIT ISSUANCE 10. -FLo0020NE A.b.U.C.
W �_ COMI'IiNSAT'ION INSURANC PLG.CONTR. LIC.NO. PLG.
I leted if the(This section need not be cora
CL O p permit is far one TOTAL Y N V ,N
Z hundreJ dollars($100)orless.l -
U O 1 Certify that in the performance of the work for which alis per-
IL F mit is issued,I shall not employ any person in any moaner so as to QTY. MECHANICAL PERMIT FEE FEE SUMMARY
U become subject to the Workers'Compensation Laws of California. An
Ed Date BUILDING
- Applicaut - /��•
} N NOTICE TO APPLICANT: If,after making this Certificate of lix- ALTER OR ADD TO MECH. 5.00 I
F Z emption,you should become subject to the Workeri Compensaljon 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 100MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000QEM.) 6.00 SEISMIC FEE .
1 hereby affirm that them is u construction lending agency for EXHAUST HOOD(WITH DUCT). 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.UgFEESC
) 800
Lender's Name HEATING UNIT(OVER ER 100,000 B.TLender's Address ELECTRIC
1 certify that I have lead this application and state for the above VENTILATION FAN (SINGLE)
information n correct. I agree t0 comply with all city and county PLUMBING
infor atio and olmc laws relating to building Coity an ion, and BOILER-COMP(3 H.P.or 100,000 B.T.
hereby aulhorho representatives of this city lie enter'umb the BOILER-COMP 1Ovar 100,000 BTU)SEE MECHANICAL
above-mentioned property for inspection purposes.agree 10 jRd nn ya s harnhlc s the City of MISC.- REFER T �TCupertino N4f hit IiI I I r Pts, sand pensee which - CONST.TAX �Vmay in y way a rue al said •quince of t e PERMIT ISSUANCE �
grand 0 this it. ///_bb MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL 2-OS-
icant/COntra or Date ,
- OFFICE COPY t