09995 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
A IILDING PROJECT IDENTIFIC PERMITNUMBER
ea,aa, APPLICATION & PE
A( Q G2./L ft BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 09995
OWNER'S { PLAN CHECK VALIDATION
NAME TY. ELECTRIC PERMIT x FEE
PHONE r �-f o
CONTRACTOR'S
ry x' UTLETS-SWITCHES•RECEP 10.00/1.00
ITS SyuC.No- j/ LIGHTING FIXTURES 10.00/1.00
( CONNTTR�AyyC�TT.O.��R'S sl*rwro do NM1,V II/O PPLIANCES-RESIDENTIAL 4.00 ,
� PHONPANELS 10.00 � DATE OF APPLICATION
ARCHITECTPLAN CHECK FEE P.C.NO.
oR � CO PANELS (OVER 200 AMP) 20.00
- ENGINEER
uC.No. 1.7r SIGNS TRANS. 3.00
ARCH.OR END. PERA Vj1 LIDDATION
ARCH.OR,y t. A,TO CM �'S(/ ✓A'L6 /01 SPECIAL CIRCUIT 5.00 .'•.A!■
Z�C� p p EMP. METER OR POLE INS. 20,00
APPLICANT'S MOTORS SEE FEE SCH. )JQ 2
iauSUN,,riG 6tir,�flRAl� 7X986
^7 5V� SERVICE CHANGE 20.00
0 0 0 LICENSED CONTRACTORS DECLARATION TEMP.POLE PAID 30.00 Clty of CUpOrtiff
a u U I hereby affum Ihat I am licensed under provisions of Chapter 9 - VISSUANCE Y ATE
z w (commencing with Stenon 7000)of Division 3 of the Business and
2 Professions Code- I my license is in fW force'n (J� �- r r BLDG. ELECT. PLG. MECH.
Z, o w - License Class_�2_Lia Nuan
4 y H w Dale Contractor e t
m - 'BUILDING PERMIT
Ic w 1)1: Df:CLARATI ��/I I U
a~ y MISC.- - REFER TO OR INFORMATION.'
X ; 0 w Iherebyfth affirm That I am exempt from the GiessandP s L Isla VALUATION $/FT.
ILO ¢ Law for the following reason.(Sea 7031.5,Raciness and Professions 10.00
in in
aa g PERMIT ISSUANCE
Code:Any city or county which requirese permit to construct,alter,
Q Q O O improve.he applicant repair h permit to file
pa sign d s issuance,also ELEC.CONTR. LIQ NO. ELEC. '�
¢ requires the applicant for such permit to file a signed statement that TOTAL p gMIT TO
n w m he is licensed 9(commencing mot to the provisions of the Contractor's License
zi buw fess andr9sionsodewith Section is 00)of exempt theron3of(he
f 4 o Business and Professions Code)or[hal he is exempt therefrom and QTY. PLUMBING PERMIT FEE
(cH $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n ; by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5,00 2L
' of not more than five hundred dollars($500).):
❑.1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 4.00
their Sole compensation,will do the work,and the>,H!,b Cis no OCQ,GROUP RE'.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND: 5.00 / 7J•F//1
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve- •'
or nts o.notimprovement is sold w thin on yearsale.o IL however,if,,buildingowner-
builder
GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of he completion the owner-
builder will have the burden of proving that he did not build or int- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BU
ILDwG USE
prove for purpose of f the.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON pB Otnsr
❑ d as owner of the property,he exclusively. 7044, ins with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code The Contractor's License Law does not apply
toan trowner of property who builds or trimprovesenseduand who LAWN SPRINKLERS-OVER'5(EA.) 1.00
contracts tractor's
such projects with a contrndoHs)licensed pursuant to
the Col muese License Law. SEWE R-SANITAR V-STORM EA.200ft/10.00 O. TRACT NO. PARCEL NO.
❑ tum exempt tinder Sec. ,R.&P.C.for this WATER HEATER W/VENT 6.00 /
reason
Owner _ _��Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WO RL IFR OM PIiNSA ION DECLARATII N WATER TREATIN EQUIP. 5.00
• 1 her y affirm that I have a certificate ofconsent to sel&insure, . ZONING ENG.SITE NO.
•Or a cert 'tale of Workers'Compensation Insurance,oTr ..0 certified
copy there Sec.3800,Lab.C.).��dA� 7
O P li y No Company A
'rtified copy is hereby furnished. GQ FIRE SPRINK ENERGY TZC
Z Cer'fie c py is tied dh he ity inspection it
� p pplicunt ( ,. MI FER TO ORD. v0 N� Y ❑ NO
CC W :RTIFICATE OF EXIiF1PTIONF OM WORKERS' PERMITI 10.00 FLOOD ZONE A.L.UA.
LU - COMPENSATION INSURANCE PLG.CONTR. LIC.NO, PLG.
CL o .(This section need not be completed if the permit is for one TOTAL, Y NV ❑ N�
:D Z hundred dollars($100)or less.)
L) O I certify that in the performance of the work for which this per- QTY. . MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued,I shall not employ any person in any manner sots to
Ow heconm subject to the Workco'Contpensut ion Laws of California
Is. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} Z NOTICE.TO APPLICANT: If,after making this Cerliftcate of Ex-
F - emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with CJ FEE such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE 06D
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit Is Issued(Sec. / MICROFILM
3097,Civ.C.), roe HEATING UNIT(TO1 ;000 B.T.U.) 6.00
Lender's Name
Lender's AJdress� � pp HEATING UNI 0,000 B.T.U.)9.50 ELECTRIC
I cerlily that I have read this 'ppteti..RPF rrtl�at2t#bove VENTILATION AN (SIN 4.00 , f
information n correct. I agree to comply with all city and county PLUMBING
ordinances and slate laws relating to building construction, and BOILER-COMP( P, r 0 OB.T.U.) 6.00
hereby authorize representatives of this city IO outer upon the BOILER-COM (Over 100,000 �E FEE$CH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to sayy, indemnify and keep harmless the City of MISC.- ER TO ORD.
Cupertino against Eilities,judgments, costs and expenses which i CONST.TAX
may in any way ' true against said City in consequence of the PERMIT ISSUANCE 10.00
Storting Of this n' , MECH.CONT. LIC.NO. MECH.
/ /D TOT
A TOTAL
Slgnat n ontractor Date _N
OFFICE COPY