15494 (3) I
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
.
BUILDING PROJECT I DENTIFICATION PERMIT NUMBER
ADDRESS APPLICATION & PERMIT � .��,�� .
ADDRESS
x f v ! S _�U 8 DING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S/'I /� A `
_ ME `, rF �E 1T 11 GG, /�S'c�d C PLAN CHECK VALIDATION
QTY. ELECTRIC PERMIT FEE '
NE
NpMERAcrORs , --// UTLETS-SWITCHES-RECEP 10.00/1.00
I' LAt I O ( NO. 1.p C LIGHTING FIXTURES 10.00/1.00 ,
� CONTRACTOR'S
- DREss ( YYS APPLIANCES-RESIDENTIAL 4.00 -
33 PANELS 10.00 DATE OF APPLICATION
ogclnrecT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.No.
ENGINEER j-1
/! L.C.No. SIGNS TRANS. 3.00
ARCH.OR ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCH. ��/J,1 ��(�,(/,,/y�✓�`�
SERVICE CHANGE 20.00
C'
o o LICENSED CONTRACTORS DECLARATION
<i w 1 hereby affirm hat 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
y ¢ (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H M i Professions c,and m llc roc is in full fore ldf-�ct. ❑ ❑ ❑
z O a- License Cla' Lia Number Z ,
4 H r
w Datc_,/ _Ctrac.1r,
am2 , IkV ILDING PERMIT .
¢ o Z u OWNER-BUILDER DECLARATION %,
F 1, LL r . 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD INFORMATION
F .. o J Law for lire following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 vALUA $/FT.
m� Code:Any cityorcounty whichreyuiresapemiitmconstruct.alley,
K ¢ ¢ improve,demolish,Or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
LL requires the appll Capt for Such permit 10 file a signed Statement that TOTAL PERMIT TO
n w m he is licensed pursuantto the provisions of the Contractor's License
rzi Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
E 4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
W $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a3.. by any applicant for a permit subjecus the applicant to it civil penalty -
1' ALTER-DRAIN (EA.) 5.00
ofnot more than fivehurdred dollars(5500).1'. -
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for Sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law docs not apply to an owner of -
property who bndds or ialpttiveS MichCon,and who does Such work FIXTURES-PERTRAP 5.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himself or though his own employees,provided that such improve
I marts are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM611NC.40UTLETS 6.00
or improvement is sold within uric year of completion, the owner-
builder will have the burden of proving that he did not build or hit- GAS-EA.SYSTEM-OVER 4 IEA.)' 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES IND CON PB Omer
Ci . .
1,as owner of the property,um exclusively contracting with ❑ 11 El ❑
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
to an owner of property who hudds or improves thereon.Imd will, LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuam Io' SEWER-SAN V-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,ILAP.C.for flus WATER HEATER W/VENT 6.00
reason
Owner Data WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
l-'W KI!RS' OOM/PENSSATI0 ])UCLA A'I'ION WATER TREATING EQUIP. 5.00
I BBrc�yn701/mv?R gy'e �eoPcla sal Ginsum, -
or r certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO,
cppyylkfeo!(Sea 3800,Latin Cpeau, 1.
Poo h6 Company !_ '
Q ❑ Certified copy is hereby furnished.
Z Z m/Certifie py filed w'h tt city it •cY ''ision. FIRE SPRINK " ENERGY T-24
H O Applic:ut MISC.- REFER TO ORD. Y ❑ N❑ I Y [D NC
ir r2 CERTIFICATE.OF EXE1,117ION FROM W k.RS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.G.
LU > COMP17NSAI'ION INSURANCE PLG.CONTR. _ LIC.NO. PLG.
CL Cl Cl section need orf be completed if the permit is for one TOTAL Y O ' N Y❑ IN
-D Z hundred dollars IS 100)or CSS
U O '1 certify that in the perfornwnce of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil is issued,I shall not employ any person in any manner m as ll,
Ow hecomesubject to the Workers Compensation Laws of California.
Q. Dam Applicant - ALTER OR ADD TO MECH. 5.00 BUILDING �CL�Sb.
} w NOTICE TO APPLICANT': If,after making this Certificate of 17,
♦- ? emption,you should become subject ill the Workers'Compensation APPLIANCE 5.00 PLAN CHECK (,/f�
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=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000GRM.) 6.00 SEISMIC FEE
I 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.L 'HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that l have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
� information is correct. I agree to Comply with all.city and county PLUMBING� ordinances and slate laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby enthorim representatives for
oriins inspection
this city to enter upon the - BOI LER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property tativsp of
purposes.
(WC) 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 against said City In consequence of tire
fir
=is his permit -WI -86-
� MECH.CONT. LIC.NO. MECH.
r TOTAL TOTAL 7� 9a
Signature of Applicant/Cont i Um
OFFICE COPY