5466 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE U&LL POINT PEN ONLY
BUILDING PROJECT IDENTI FIC�N PERMIT NUMBER
BUILDING, APPLICATION'& PE IT
j• AODR ss _r/ 5466
/�-ESGcLTS BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNERS MEh5cIl2CX '. - _ .
PLAN CHECK VALIDATION
DTV. ELECTRIC PERMIT FEE -
Mll=e ' .lfiE�lScrJ- m.NE 2sr /Sao
CONTRACTORS UTLETS-SWITCHES-RECEP 5.00/1.00
1,0� W^' �1-/�•p•- ."uC.N0, Q
LIGHTINGFIXTURES 5.00/1-.00
AcroRs C-
ADDREPPLIANCES 1 RESIDENTIAL 4.00
-f�'L
-
PANELS "S.00 DATE OF APPLICATION
ARCHITECT Mo E SS6 C/A SIGNS 6.00 PLAN CHECK FEE - P.C.NO.
OR
ENGINEER /•
LIC.No.` FZ73 SIGNS TRANS. _ 3.00 `
AHC..OR ENG, SPECIALCIRCUIT 5.00 r - ,. - PERMIT VALIDATION
ADDRESS Lam, /I�-T�-S -
!C.3 - 2N D /�, ,, EMP.METER OR POLE INS. 15.00
AR SS MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
APDD
APPLICANT - - '
Foo r LICF:NSIiD CON'T'RACTORS DECLARATION
I herchy uffinn that I am licensed under provisions of Chapter 9
Nan (commencing with Section 7000)of Division 3 of the BesIRCSs and ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
H'N z I'mfessiom Cole,,�Iy{7 my license is in ftd Lfom� , Cecl. - ;
n .o i,n G License Lic.Numbe�� `� El El �' j� d
,A E Dme_Li_ 7_9'x-_Cnnnactor
A, x -' UILDING PERMIT-
' ¢-¢ w a flWNli R-Ii LIILDCIt DEChA RA'T'ION - -
O a " MISC.- - REFER TO ORD INFORMATION
X ;LL N 1 herchy affirm that I am exempt from the Contractor's License �I
S_
O Law for the following reason.(Sec.7031.5,Busineasand Professions - r7�'Vv1/,A�IOaN.d $/FT.
H PERMIT ISSUANCE 6.00 1 d/lYT7J8�U1,
- Cade:Any city orcounly whiclirequiresapern:illnconslruct,altcr,
¢ aO O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
A, SE ¢ requires the applicant far such permit to file a signed statement that TOTAL
A'w m LL 'he is licensed pursuant In the provisions of the Contractors License Cu,�1fj.�{I I1p1PERMIT TO N /
riQLaw(Chapter 9(commcncing with Section 7000)of Division 3 oflhe /%C L'L%JNiN�
4 O Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
aC I- w the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE.CONSTR.
..ate _ by any applicant for a permit Subjects the applicant ton civil penalty
ALTER-DRAIN& VENT-WATER (EA.) 4'.00
of not more owner
five hundred property,
o fmy em:
❑ I,as owner at the property,or my employees Withrust re is not BACK FLOW PROTECT.DEVICE" 2.00 OCC.GROUP. RES UNITS
their sole compensation,will do the work,and the structure is not -
code: ri or offered for salt(Sec. 7044, Rosiness and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 '
Code:'fhc h o builds r'i License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTALACREAGE
• himself or through his own employees,Provided that such improve-
ments arc not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
ar improvement is sold within one year of completion,the,owner- GAS-EA.,SVSTEM-OVER 4 (EA.) 1:00
r hUllder will have the burdeD'of proving that ha did not build or int- BUILDING USE
prove for purpose of e.). h ❑RES t❑ ❑N ❑ Other
❑.f u th
owner of the property,am exclusivCly,contracting with INDUSTRIAL WASTE INTER. 20.00
licensed contractors to construct the proiect(See 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 - ASSESSORS PARCEL NO,
and Professions Code:The Conlractor'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 fur such projects with a contraCt.,S) weaned pursuant 10 '
the Contruclori Licmhu Law. SEWER-SANITARY-STORM EA.200ft/8.00 'TRACT NO.. PARCEL NO.
❑ Imnesemplundcr .Sec ,B.&I'.C.far this
reason WATER HEATER W/VENT 4.00 '
Owner Date WATER SYSTEM 4.00 - ACC.DATE ACC.FILE NO.
- WORK IiRS'COMPI'NSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a cerlific:du of consent In self-insure, ZONING ENG.SITE NO.
Or a certificate of Workers'Compensation Insurance,or a cerlil'ied
copy thereof(Sce.380Q labp.).
I'olicy No,_- C.... Y "
'C ❑ Cend ypy is hereby furnishe FIRE SPRINK ENERGY T49
-z Z` ❑ Cerl if �C1r� s t•d r 'th Ih L'ty inspection division.
Ei Appliruht_� "-'- MISC.- REFER TO ORD. 'Y ❑._ N❑ Y ❑ N❑
•~ w' PERMIT ISSUANCE 6.00 C
-�.- CIiRTII'ICATE OP EXEMPT'ION FROM WORK. S' ' ' FLOOD
i LU > ' COMI'P.NSATION INSURANCE PLG.GONER. LIC.NO. PLG.
('f his section need not be completed if the permit is for one - TOTAL' Y❑ N❑ Y ❑ N❑
U Z hundreddollars(SI00)orleSS,) y - -
U O Icertity 0hat in the performance of the work for which this per QTV. . MECHANICAL PERMIT FEE FEE SUMMARY
LLL I- mil is issued,I shall not employ any person in any manner sn us to
U W become subject to lite Workers'Compensntmit Lows of California.
y Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDINGS-V
'} W NOTICE '10 APPLICAN"1': If,after making this Certificate AFT...
F Z caption,you should become subject to the WorkeD'Conhpensation APPLIANCE - •4.00 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 10=11F.M.) 3,00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000GEM.) 5.00 SEISMIC FEE /Q t'PS
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the perl'nnnance'of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ..ELECTRIC „
I certify that 1 have read this applicatian and state if the above VENTILATION FAN (SINGLE) 3.00
information is correct.I agree to comply with alt Lily and county PLUMBING
ordinances and slate laws relating to building c,Axlruclion. and BOILER-OGMP(3H.P.D}100,000B.T.U.) 4.00
r.
hereby authorise representatives of this city to ewer upon the BOILER-COMP IOver 11X1,000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes..
(We) agree to save; indemnify and keep harmless the City of MISC.- - REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which - - - CONST.TAX
may in any way accrue against said City in conuiluence Of the PERMIT ISSUANCE 3.00 _
gr. : g of this pernsIt. MECH.CONT. LIC.NO. MECH.
�_7- TOTAL TOTAL SF/
hgnature of Applicant/C'nntraclnr Dale
OFFICE COPY - '