14274 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATION PERMIT NUMBER
BGILDING APPLICATION & PERMIT
ADDRESS
t'
JIBUILDING —ELECTRICAL—PLUMBING—MECHANICAL 14274
Ul h Jc•I s'+ I-
OWNEN'S
EPLAN CHECK VALIDATION
{) Si L�'� / DTV• ELECTRIC PERMIT FEE
CONTRACTORS
AME / OUTLETS-SWITCHES-RECEP 10.00/1.00
f` •F .. xc.j LIC.NO,�' ' 'a_ LIGHTING FIXTURES 10.00/1.00
CONI ACTOR'S
.� ADDHEss js1+,• a)L0S APPLIANCES-RESIDENTIAL 4.00
z-4 /J'-r PHONE 4'i jt 35 PANELS
ARCM T ECT IO.00 DATE OF APPLICATION
ONGINEEN n PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C,NO.
uc.No. SIGNS TRANS. 3.00
ARCHON ENG.
ADOREss SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
zIP EMP.METER OR POLE INS. 20.00
APPLICANTS
AooREss MOTORS SEE FEE SCH.
X
SERVICE CHANGE 20.00
o
_o O LICENSED CONTRACTORS DECLARATION
ri w 1 hereby affirm that I am licensed under Provisions of('haptvr 9
¢ (cm,nienciRg with SCdion 7000)of Division 3 of the Busine»uuJ ISSUANCE DATE
H n i Professions Code,aqJ try license is in lull I'orcr unit effect BLDG. ELECT. PLG. MECH.
$O N N D Lll'CnSe CIaS Jr , j G ❑ ❑ ❑
Lic.Number L !
F E Dalen. Contrucwr �SL/Yusy1!e
¢ y J .
¢ a w < OWNER-BUILDER Df-CL\RATION BUILDING PERMIT
p O p O
W ; y I hereby atfinn that I con exempt limn the Contrartur's Licmu.• MISC. — REFER TO ORD INFORMATION
Huo J Law for the followingrouson.fSec.703L5.BusinrsamWl'rufessiuns PERMIT ISSUANCE VALUATION S/FT.
q Code:AnY city or county which rcyuirtsa pcnnit to cumtruc4alteq 10.00
W ¢ ¢O improve,demolish,or repair any structure,prior to its issh,,c,,also ELEC.GONTR, LIC.N0.
D u requires the uPPlicanl for such pcnnit to filo a signed Mamowrrt thin ELEC.
p
to it is licensed punuaot to the provisions of the Contractor's License TOTAL PERMIT TO
F. za Law(Ch.pter'l(commenetng with Sc Sion 7000)oi Uivision3ufthe / �
Business end Professions CDJL9 or tllm hr i,axempt tterrl'rom and QFAS PLUMBING PERMIT FEE
a =$ the basis for the alleged exentpnion.Any riW anion nl'Srcl ion]031.5 /
A. by any applicant fora pcnnit subjects the applicant toacivil penalty' STORIES TYPE CONSTR.
of non more tlun live hundred dollen(5500).1: ALTER-DRAIN -WATER (EA.) 5.00 —"
❑ I,as owner ul'the prupen>',ar my ewpluyres with wayc,:'s BACK FLOW PROTECT. DEVICE 4.00
their sole Compensation,will do the work,unJ Ina sl np9urt'a not OCC.GROUP RES.UNITS
intended ur offered
or sa4 (Sec. 7044, tlusinr» mW I'roliviun,
Code:The Contranor i Licansr Luw Does not apply loan owner of DRAINS-FLOOR,ROOF,AREA,GOND. 5.00 3 _
proptny who builds ur improves thereon,.nJ who tlwro such work FIXTURES-PER TRAP
hinucll or thmugll his own employees,proridcA that wch inn Preto 5.00 — so.FT.rLOOn AHkA TOTAL ACREAGE
' • mems are not innndcd or offered for sole.It;however.the budding GAS-EA.SYSTEM-I INCA OUTLETS 6.00 .
or hnprovemem is sold within one year of conq+lotion. nlla uwuer
builder will have tn•burden of pray log❑cot he did not build or inn. GAS-EA.SYSTEM-OVER 4 (Ei 2.00
Prove
for purpose of ,l') BUILDING USE
❑ I,as owner 01 'it.Property.ant exclusively C.mm,ing with INDUSTRIAL WASTE INTER, 30.00 RES IND CON PB Other
P pc ❑ ❑ ❑ ❑ ❑
licensed contractors m ounvrucl the project(Sec 7094, Nosiness
and Prokssions Code:The Ccmar,cm'i License Luw doesnotu I' LAWN SPRINKLERS- i INC V.B. 6.00 ASSESSORS PARCEL NO,
to an owner of Properly who builds of improves thereon,unit xho
contracts for such projects with a conuacmrls)licensed LAWNSPRINKLERS-OV ER5 (EA.),•y 1.00
tet Contractor's License Law, pursuant m SEWER-SAN ITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
reason
,B.kP.C,for this WATER HEATER W/VENT
Owner Uute I - 6.00
WATER SYSTEM ` 5.00
WORKERS'COMPENSATION DECLARATIONACC.DATE ACC.FILE NO,
I hereby affirm thus I hove a certil icute of consent w sclhinxvo, WATER TREATING EQUIP, 5.00
or a certificate ul
Workers'Cam PCnsul ion Insurance,or a certified "
copy thereof(Sce.3800,Lab.C.). ZONING ENG.SITE NO.
Policy No._Company
0 O Certified copy is hereby ILrnuhed.
7— ZZ�� ❑ Certified copy is filed with the City ItuPection division. FIRE SPRINK ENERGY T24
V/
Applicant MISC.- REFER TO ORD. r❑ N❑ v ❑ N❑
O- _ CERTIFICATEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00
LIJ COMPENSATION INSURANCE FLOOD ZONE A.L.u.C.
1 O PLG.CONTH. LIC.NO, PLG. 9
nphis section need or be eomPleled if the permit is for one TOTAL �] Y❑ N❑ Y❑ ❑
hundred dollars(S 100)Pe form N
V O I certify that in the Performance of the..,it I'ur which this
LL U mit is issued,I Shull not employ s I OTY. MECHANICAL PERMIT FEE FEE SUMMARY
P Y any person in any manner so as Io
O ED become bj t m the Workvn'Co pen•aU o Culilurnia.
} y Darc�f js/_fL Applicum .. .1111."� BUILDING
y NOT LTO APPLICAN'G II;yf 'r ma tl.'ny.thu Cert ificatc of li x- ALTER OR ADD TO MECH. 5.00
I— Z anption,you should become sut,et to the Wurken'Cmnpanmtion APPLIANCE
Provisions of the 1-ober nCodr, you must
V such provisions or this penil shall be deemed re,.kcd.
forthwith calnply with 5.00 PLAN CHECK AIR HANDLING UNIT(TO 10 FEE
p00C.F.M.) 4.00
CONS'I'RUCI'DON LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
1 hereby affirm that licit, is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this pennil is issued(Sec.
30 ,'s .Name
e
rdc � HEATING UNIT (TO 100,000 B.T.U.) 8.00 MICROFILM
3097, i
Lender's Address H EATI NG UNIT(OVER 100,000 B.T.U.19.50
Iettlifythat l have read this application and slate that the above VENTILATION FA N (SINGLE) 400 ELECTRIC
in formation is correct. I .gree to comply .,It,all city unit county
rdinances and slate laws relating to building construction, unit BOILER-COMPO H.P.Or 100,000 B.T.U.) 6,00 PLUMBING3S_In
•ove- mpresenlalives of this city to enter upon the
authorize ve-mentioned properly for inspection purpose'. BOILER-COMP (Ovur 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indenmify and kcrp hannleso IIIc City'of MISC.• REFER TO ORD.
Cupertino against Iiabil b".judgmrnls. cull, and rxprmc,wbNb
may in any way accrue against yid s u-Iis Cilit, ton>eyuenlx of tu. PERMIT ISSUANCE 10 00 CONST.TAX
gran ' b ,
r
! /tae r UC.NO. MECH
.
r per j'i%S —�! MECH.CONT. TOTAL
7•' Si r,hwrr of nl it ilcom actor TOTAL
✓ CPFICC COPY