63845 y
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
& PERMIT
BUILDING — ELECTRICAL— PLUMBING — MECHANICAL
PERMIT NUMBERBUILDIAPPLICATION
6384
ADDRESS
OD147 gas sfr�GHS e� ���
OWNER'S
NAME /
/TD �S�l/07
I !f ((NONE
QTY. i''x`, ,ELECTflIC PERMIT'.,'"., ,FEE,
x a -
PLAN CHECK VALIDATION
DATE OF APPLICATION
CONTRACTORS
NAME 3 311
u Ia- "d, 5 ,L%po.
OUTLETS -SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
ADDRESS R3Q� Svc,
Aoon/ess o )Cr.l'�-
!( 031 PHONE —72%2
APPLIANCES -RESIDENTIAL 4.00
PANELS S.00
ARCHITECT
ENGINEER 0,2A0x1L LIC.'
c. No.
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCR'ESS Oil ENO'
SPECIAL CIRCUIT ,'5.00
PERMIT VALIDATION -
ZIP
EMP. METER OR POLE INS. 15.00
r0
Ars
DRESS ES$
ADDRESS
-j 7y�Me
MOTORS SEE FEE SCH.
SERVICE CHANGE10.00
LICENSED CONI RAcroits DECLARATION
I herehy affirm that l am licensed under provisions of Cbapler 9
(commencing with Section 7000) of Division 3 of ole Business and
Professions Code , anJ m I is in full force and effect.
License Class G' Lie. Number
ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
Date Contractor 51 .S
owNER-Ruu.nr:R In
n:cLARnoN .
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason.(Sec.7iresa itocndtruct, alone
t nt.nslmdss OCq
Code: Any city., county which structure permit prior
improve, demolish, or repair any structure, prior In its issuance, also
reunites the applicant for such permit to file a signed statement that
Ile iS llurosed pursuant to the provisions of Ibe Conlraclar's License
with Section 7000) ofDivision 3 office
and Professions Code) or that he is exempt therefrom and
BUILDIN
�'G`P,ERMIT
`INFORMATION
- - -
IMISC. — REFER TO ORD
PERMIT ISSUANCE 6.00d
VALUATION $/FT.
��617��
D
ELE9, CONTR. LIC. NO. ELED.
TOTAL
-
CITY. PLUMBING PERMIT
�J, i�Egou 04/�'yLaw(Chapler9(conmencing
FM,J,(/�,1e,,JJyBusiness
` !the
basis for Ilse alleged exemption. Any violation of5ection 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
ofnot more than fivehundred dollars(5500).):
lWl
��C�
TYPE CONSTR.
rtmo
ALTER-DRAINSt VENT-WATER(EA.)4,00�fi
❑ I; as ownerol'the properly, or my umployets with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 2.00OCC.
GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AR EA, COND. 4.00
intended or Offered for sale (Sec. 7044, Business and Professions
Code 'file Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work
himself or through his own employee's, provided Ilial such Improve-
mentsare riot intended oroffered for sale. If, however, the building
FIXTURES - PER TRAP 4.00
GAS-EA.SYSTEM-11NC.40UTLETS 4,00
50. FT. FLOOR AREA
TOTALACREAGE
or improvement is sold within one year of completion, the owner.
builder will have (be burden of proving that he did not build or im-
provel'arpurpouofsalC.l�
❑ I, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 1.00
BUILDING USE
RES IND CON Pe Other
❑ ❑ ❑ 0 ❑
INDUSTRIAL WASTE INTER. 20,00
licensed contractors to construct the project (Sec. 7044, Rusiness
and Professions Code: fire Contractor's License Law,does not apply
to an owner of property who builds or improves thereon, and who
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contractorts) licensed pursuant to
the Contract.,', License Law.
❑ tom exempt Lader, Sc._, R&P.C. for tlli,
on
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 4.00
Owner Date
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
WORKERS'COMPENSA'fION DECLARATION
1 hereby action than I have a cnrtaicma of eanscut 10 'elf -mune,
ZONING
ENG. SITE NO.
or a eerfificale of Workers' Compensation Insumnee, or a certified
copy thcreoffSec 3 0 L(�?a�b.CJ.n �� �
Policy No.RG12 10te,91y—ROZ'¢/V(p9C�Ft�
❑ Certified!<apY is hereby fvrlds d.
FYCerfillie�d copy ,� �is� fit it with the ci y ins➢e�tion division.
Applic;ll,t-SJyfs.-/lMkt9l�Fo"
_
FIRE SPRINK
Y❑ NE]
ENERGY TQ4
Y❑ NC]
MISC.- REFER TO ORD.
PERMIT ISSUANCE 6.001
CBRTIFICA'I'It OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This secli6n need oaf be completed if the permit is for one
FLOODZONE
Y ❑ N
A.L.U.C.
Y ❑ IN
PLG.CONTR. LIC. NO.
PLG.
TOTAL
hundred dollars IS 100) or less.)
I certify That in the performance oPerwln n anyfor
mlf Is issued, I shall not employ an manlncr'ulsos to
oTY; a - `awe'^.: ,MECHANICAL',P,ERMIT �„s,,„ s ,Y`+.FEEa.
..
"
r
- FEE�SUNIMARMa
-'•• ^
BUILDING
M Q Q
becomesublecf to the Workers'Compensation Laws of California.
Date Applicant
NO71C1: TO APPLICANT; 11 ul ler making this Certificate of lA.
ALTER OR ADD TO MECH. 4.00
APPLIANCE 4.00
AIR HANDLING UNIT (TO 10p000.F.M.) 3.00
PLAN CHECK
FEE
�%)
/O• 111r `�
elliptical, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall he deemed revoked
AIR HANDLING UNIT(OVER 10J=C.EM.) 5.00
SEISMIC FEE
*41010
CONST RUCTION LENDING AGENCY.
I hereby affirm .hal there is a conslruclion lending agency For
the performance of file work for which this permit is issued (Sec.
3097, Civ.C.).
EXHAUST HOOD IW ITN DUCT) 2.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's e
Nam
I.endei s Names,
HEATING UNIT 100,000 B.T.U.)7.50
ELECTRIC
VENTILATION FAN (SINGLE) 3.00
I ecriuy that 1 have read this dpplicatimi and Stale that the above
Information is correct. I agree to comply with all city and county
ordinances and stale laws relating to building construction, and
hereby aulhorile representatives of this city, to enter upon the
above-mtnlioned properly for inspection purposes,
PLUMBING
BOILER -COMP (3 H.P. of 100,000 B.T.U.) 4.00
BOILER -COMP IOwr 100,000 BTU( SEE FEE SCM.
MECHANICAL
(We) agree to save, indemnify and keep harmless the City of
MISC. - REFER TO ORD,
-
Cupertino against liabilities, judgments, costs and expenses whicll
may in any way ue aqui t said Ci in consequence of the
gra 'Ago his I.
PERMIT ISSUANCE
CONST. TAX
MECH. CONT. LIC. NO, MECH.
H.
7._11— k�4
TOTAL
TOTAL
"
Z(,y0
Igna ore of Apphcanl/Contractor Date
OFFICE COPY