10954 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY 570
.QUI LDI NG PROJECT I DENTI FICA - PERMIT NUMBER
BUILDING r , T APPLICATION & PE r 10954
ADDRESS
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S ✓� - PLAN CHECK VALIDATION
IA"'' TV. ELECTRIC PERMIT FEE• 1
,fi• Ci' C VCi PHONE ,]/' /L�
croRs
NAME • OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
C4111)71 tew� d��r. CO, uc.No. /,r.3 LIGHTING FIXTURES 10.00/1.00 -
CONTRACTOR 6 - PPLIANCES-RESIDENTIAL 4.00
ADDRESS p
as e/,42612 S�PHONE �oSS6 PANELS 10.00 DATE OF APPLICATION
ARCHITECT - PANELS (OVER 200 AMP) 20.00 PLAN CHEEKFEE P.C.NO.
OR
ENGINEER
Lie NO. SIGNS TRANS. 3.00 - -
AooREOR ss ENG. - SPECIAL CIRCUIT 5.00 PERM�VA11�rION
ZIP EMP.METER OR POLE INS. 20.00 Cp /M1
ADDRESS GD
MOTORS SEE FEE SCH. F 2 J 1986
S C'/j�a�'�FS d� SE ,S/' SERVICE CHANGE 20.00
w 0 2 - LICENSED CONTRACTORS DECI ATION City OIL
CUp rinO
¢u u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
Z,w (commencmg with Section'7000)of Division 3 of the Business and
}�A Q a ELECT. PLG. MECH.
H w z Professions Cod o�`d m license is in full force and eff e,. ❑ ❑ ❑
Z, Z x W License Class Lie.Number
Dale Contract.,
BUILDING PERMIT
¢ o a U OWNER-BUILDER DECLARA'PION INFORMATION
E:
5 LL w 1 hereby affirm that I am exempt from the Contractor's Licens MISC.: REFER TO ORD VALUATION S/FT.
H n 0 J Law for he following reason.(Sec.7031.5,Businessand Profeesi s PERMIT ISSUANCE 10.00
y0 Code: ny city orcounty which requires a permit to construct ter,
S improve demolish,or repair an structure,prior to its issua e,also ELEC.CONTR. LIC.NO.
¢ rE¢ O p o' Y p ELEC. -
O¢ requires t applicant for such permit to file a signed stat ent that TOTAL PERMIT TO
d w m w he Is been, pursuant to the provisions of the Contra or's License
r z a Law(Chapte 9(commencing with Section 7000)of rvision 3 ofthe - - a 1
EEO Business and ofessions Code)or that he is cxe pt therefrom and QTVf PLUMBING PERMIT . FEE
¢ H a the basis for lh -Ileged exemption.Any viola o of Section 7031.5 - - STORI - TYPE ONSTR,
n3 _ by any applicant r a permit subjects the a heart to a civil penalty ALTER-DRAIN -WATER ( .) 5.00
of not more than a hundred dollars(S ),I:
❑ I,as owner o he property,or y employees with wages as BACK FLOW PROTECT. DEVIL 4.00 OCC.GROUP RES;UNITS
their sole compensati ,will do th work,and the structure is Hol
intended or offered fa sale IS, . 7044, Business and ProfessionsDRAINS-FLOOR,ROOF,AREA D. 5.00
Code:The Contractor's 'cen aw does not apply to an owner of
• property who builds or irn ves thereon,and who does such work IP FIXTURES-PER TRAP 0 0.IT.FLOOR AREA TOTAL ACREAGE
himself or through his ow ployees,provided that such improve-
meatsarenotintended rof ed for sale.If,however,the building G, S-EA.SYSTEM-11 NC(4 OUTLETS 6.OU
or improvement is so within c year of completion,the owner- GM;-,,EA.'SVSTEM-OVER 4(EA 2.00
builder will have t bumen of p sing that he did not build or im- BUILDING USE
prove for purpo of sale.L INDUS A.AL WASTE INTER. 30.00. IND CON PB other
❑ I,as o r of[he property,a exclusively contracting with
licensed e. actors to construct the eject(Sec. 7044,Business LAWN SPR IN LERS-1 INC 5 V.B. 6.0 ASSESSORS PARCEL NO.
and Profe ons Code:The Contractor's L ns e Law does not apply '
to an o net of property who builds or am vex thereon,and who LAWN SPRINK S-OVER
cont is for such projects with a contructor(s 'tensed puma unt to SEWER-SANITA EA.200ft/10.00
th mAractor's License Law. TRACT NO. PARCEL NO.
I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/ NT 6.00
eason
Owner Date WATER SY EM rnSt �� •5.00 ACC.DATE ACC.FILE N0.
WORKERS'COMPENSATION DECLARATION WATER T EATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure, p -
or a certificate of Workers'Compensation'Insurance,or a certifictl see"-,45x-V / ZONING ENG.SITE NO.
colic (Sec�800
0Q Lab.Q)
PoNoSlr-1 .company
O 0 Certifiedcopyisherebyfu.r/nYi-shM/ed.
FIRE SPRINK ENERGY T 24
Z Z �' Certified copy is Bled with OBr�e city inspe Ion division.
O Applicant G�&aY�sl/�. CO- Sn� - MISC.- REFER TOORD. Y [:] NE] Y [:] NO
~ y
Lu - CERTIFICATE
EXEMPTION FROM WORKERS' FLOOD ZONE a.L.0 c.-
W > COMPENSATION
PERMIT ISSUANCE 10.00 INSURANCE. PLG.CONTR. LIC.NO. PLG.
� Z (This section need not be completed if the permit is for one T A, TOTAL Y❑ N'E] V� NEI
H red dollars($100)or less.) - L
U O I c y that in the performance of the work for which this per OT ° MECHANICAL PERMIT FEE FEE SUMMARY
IL F mit is iss 1 shall not employ any person in any manner so as to
O Wbecome suoje [he Workers'Compensation Laws n f California. `
y Date pplicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ GO NOTICE TO APPLI P: If,after making this Certificate r 'x-
� ? emotion,you should bee a subject to the Workers'Coln sation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor C you must forthwith ply,with FEE
U such provisions or this permit sh C deemed rev. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LEND NCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a concti lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for ch this per is issued f5ee. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Nam c HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
ti I certify that 1 h read this application and state that the above VENTILATION FAN (SINGLE) 4.00
yr linformation is c Dort. I agree to comply with all city and county PLUMBING
-ordinances an state laws relating to building construction,'and BOILER-COMP(3 H.P.Or 700,000 B.T.U.) 6.00
hereby aathorizc representatives of this city to enter upon the
x } "Y above-mentioned property for inspection purposes. BOI LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which' PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue again said City in consequence of the
granting of la permit. p MECH.CONT. LIC.NO. MECH.
_..�d 6 TOTAL TOTAL
ignatum of Applioant/Contractor Dale- v
OFFICE COPY