7233 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES -USE BALL POINT PEN ONLY
•� I BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING- !'APPLICATION & PERMIT
/ r
ADDRESS iq�oo. :ST>;uEt�5 cgteK. 7233
} BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S - t -� 'a" v PLAN CHECK VALIDATION
I ME
M. r1RENZ1 /���ry-/3'3 07Y ELECTRIC PERMI FEE
P#31 R,aA O r s i k +-Aw*§yv,y, v'+' , '# ;e, r:ar-
CONTRACTOR'
NAME UTLETSHTNG FISWITCHES-RECEP 5.00/1 00
'7( LIE NO;- J r� LIGIXTURES 5.00/1.00
IONFIRACTOaxPPLIANCES-RESIDENTIAL 4.00
ADDREss / J
�• 70� . ONE�IZ.�/yf� PANELS 5.00 DATE OF APPLICATION
// ARCHITECT SIGNS - 6.00 PLAN CHECK FEE P.C.NO.
OR
/'- LIC.rvo. � (. !+ SIGNS TRANS.' 3.00
ARCR,OR n LLag PEf�TjkVQ}{�lATION
ADDRESSR122-% �p 5 'qQ,��� gg SPECIAL CIRCUIT.' '5.00 rhe`/ ,
111,1864 -'2iP1�107 EMP.METER OR POLE INS. 15.00
APPUCArvr MOTORS , SEE FEE SCH.
AUDRE55 SERVICECHANGE - 10.00 NO��V 12�19i85
0 o O LICENSED CONTRACTORS DECLARATION City Of CUy..I 1�lUO
F i ar
U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
in a (commencing with Section 7000)of Division 3 of the Business and B$ I ELECT. PLG. MECH.
F w i Professions Code,and my license is in full force and effect. ❑ ❑ ❑
z o m- License Class Lic.Number -
4 w Date Contractor
yF
¢ ¢w a OWNER-BUILDER DECLARATION srl -B ILiDINO PERMIT"
a. C A " MISC.- REFER TO ORDA .N-FQRMATIUN_
is g u m I hereby affirm that'l am exempt from the Contractor's License
Fuoj, Law forthe followingreason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE - VALUATION S/FT.•
Code:Any city or county which requires a permit to construct.alit', 6.00
¢¢ 0improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. /
¢ requires the applicant for such pernit to file a signed statement that TOTAL
d.W m u he Is licensed pursuant to the provisions of the Contractor's License PERMIT±O
i Law(Chapter 9(coin me ncmg with Sect ion 7000)of Division 3 of l he
't Business d Professions Code)or that he Is exempt therefrom and DTV'.+ yell s^`PLUMBING PERMIT P x, F,EE'a -
It F o the basis for the alleged exemption.Any violation of Section 7031.5 A 4Ay
'+ +,` mF * T'^.$ STORIES TYPE CONSTR.
u ;m by any applicant for o permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.).4.00
.four more than Uvehundred dollars($500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2,00 OCC.GROUP RES.UNITS
their side coin pensntion,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractors License Law does not apply to an owner of
property who builds or improves thereon,and who does such Wolk FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
ments an not Intended of offered for sale.,U,however,the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) .1.00 BWLDIN USE '
builder will have tire burden of proving that he did not build or im- - RES IND PB Omer
' prove for purpose of sale•.). I INDUSTRIAL WASTE INTER..' 20.00
❑ I,as owner of the property,ani exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. - 5.00 ASSESSUVS PARCEL NO.
and Professions Code:The Contractors License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1,00
contmetS for Such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. - SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ Iam exempt under Sec.-,ILAPC:for this WATER HEATER W/VENT 4.00
reason
+ Owner Date WATER SYSTEM 4.60 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSA'fION DECLARATION WATER TREATING,EQUIP. 4.00 -
I hereby affirm that I have a certificate of consent to self-insure, ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.3800,LAC.).
Policy No. Company '
0' ❑ Certified copy iencby furnished. FIRE SPR INK ENERGY T-24
Z Z - Mie s fit 1 ly inspection division.
/ [�`I I;z MISC.- REFER TO ORD.
O PPlica Y ❑ N❑ y ❑ N❑
~ as PERMIT ISSUANCE 6.00
� - CEItI'I FICA COM COMPENSATION
MINS PROM WORK f:RS'- FLOOD ZONE A.L.u.C.
W ? COMPIiNSAT10N INSURANCE PLG.CONTR. LIC.NO. PLG.
C 0 (This section need not be completed If The permit is for im, TOTAL Y❑ N❑ Y❑ N❑
Z) Z hundred do1lars($100)or less.) .-
0 O 1 certify that in the performance of The work for which This per s ' *A < " v L r ri:r rs r. �„45y, 1y,A s
DTpVd'a..', q MECHANICALrPERM1T�,•:y;'" + #FEE $f .> FEE SUMMARY
sr
W F mit is issued,I shall not employ any person in any manner so as to v yt� g ', # i s _
O W become subject to the Workers'Compensation Laws of Caldbmm. ' M
Date Applicant - OR BUILDING, 7 W
} W NO'IICF-'1'0 APPLICANT: If,after making this Certificate of Ex- ALTER ADD TO MECH. 4.00 '�
♦- Z emption,you should become subject to the Workers Compensation APPLIANCE_ 4.00 PLAN CHECK,
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 10,00DC.F.M:) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00QF.M.) 5.00 SEISMIC FEE ZQ
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T:U-) 4,00
Lender's Name HEATING UN IT(OVER"100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I have read this application andstale that the above VENTILATION FAN (SINGLE), 3.00
i information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction,and BOILER=COMP,(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city.to!enter upon the
above-mentioned property for inspection purposes. BOILER-COMP(Gse1100,000 BTUI SEE FEE SCE. MECHANICAL
(We) agme to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any w ccme agar9st said City in consequence of the PERMIT ISSUANCE • 3.00 i
granting oft rants. /7 �r MECH.CONT i ^ LIC NO MECH. §d4 M' iTx
f/i/ /,,✓ - TOTAL TN0,1 i a
fAL
'gna eof Applicant/Contra r Date
OFFICE:COP,VI..Y,