6262 "' , L.IL,r"v 1 1 LJ FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
emLDINc
ADOR6ES$ APPLICATION & PERMIT PERMIT NUMBER
/�
/ 9 16vCQ. 13Z(fp, BUILDING —ELECTRICAL—PLUMBING—MECHANICAL 6 /6 /
OWNER'S ll L
NAME
• tnmjy� rpt - aY� .$
OT✓�Co PRONE /8 O'.'^y„T-k •Y {;�.. ELECTRIC PERMIT. PLAN CHECK VALIDATION
CONiRgCTOR 5 .l'A'tV',. ✓�'BL ,I FHB A
u 7o— UTLETS-SWITCHES-RECEP 5.00/1.00
K' G uc.No. /33 // LIGHTING FIX URES
ADD....
DD..ACTOR'$ 5.00/1.00
� PROs HO NE PPLIANCES-RESIDENTIAL 4,00
Agcgrtecr PgNELS
on 5,00
DATE OF APPLICATION
ENGINEER SIGNS
5.00 PLAN CHECK FEE P,C.NO,
ARCH.DR ENO. LIC NO. SIGNSTRANS-
ADDRESS3.00
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
Ars zIr EMP.METER OR POLE INS.
ADDRESS 15,00
¢ EE SCH.
MOTORS SEE F Is
° SERVICE CHANGE 10.00
F 0 o LICENSED CONTRACTORS DECLARATION �
¢ ill
EA i w I hereby g wit that 1 am licensed under provisions of Chapter 9
a a (commencing with Section 70001 0(Division 3 of the Business and
0 i Prolesimoi class
Codyyy...and my Ijeense is in full force n
Q 2 ° License CIasS cL ISSUANCE GATE
Lie.Number �]7/�L BLDG. ELECT. PLG. MECH.
a a E j DatE_(�i Coo]ractor t�.-��_
S ir i OWNER-BUILDER DECLARATION ❑ ❑ ❑ ❑
a 3 H I hereby affirm that I am exempt from the Contractor's License MISC.— ILDINO P.ERMI F
f yq
r LL o J Law for the following reason.(SEC.]031.5,Business and Professions REFER TO OR aT1:.fINFORMATI Tom.
f '"i Code:APyeedem.1 or county which req uiresaperminoconsrroeaheq PERMIT ISSUANCE DN
¢ a p improve,demolish,or repair any structure, 6.00 VALUATION SIFT.
a. X
m¢ requires the applicant for such permit to file a�fined Statement that ELEC.CONTq. LIC.NO, /Q
he is licensed pursuant to the provisions of the Confrncmr's License ELEC. V J 940 a�
I- Law Luw lChapter9(commencingwith Section7ODO)of Division3ofthe TOTAL
a Business and Proleslons Code)or that he is exempt therefrom and F-L ae'4 I
� x °
w m the basis for the alleged exemption.Any violation of ]031 5 � w(-Xw�"'°.p`r pLUMBINQ'pERMIT,yy a S _ T TO
PERMIT
A + - hY any applicant fora E /PIe� "n/K�-
permit Subjectsthe toaciv it penal tyG+?rT<r,-..w'a '#
of not more than fivehundredProp dollars(PY Em1: ALTER-DRAIN ' STORIES
❑ Las owner of the Property TYPE CONSTR.
(heir sole co P Party,or my employees with wages as (EA,) 4,00
intended or offered for sal e(Sech 70"k I anti Business e and PrUesofessions BACK FLOW PROTECT. DEVICE
Code:The Contractor's License Law does not apply to an owner of 2.00 OCC.GROUP
Property who builds or improves[hereon,and who docs such work DRAINS-FLOOR,ROOF AREA,CONO. 4,00 RES.UNITS
• himself or through his own employees,Provided that such improve-
ments are not intended or offered for sale.If,however,the budding GA$-EA.SV$TEM-11NC.40UTLET$ 400
or improvement is sold within one year Of OompletiOn, Ile Owner- SO.FT.FLOOR AREA TOTAL gcgEACF
builder will have the burden of proving that he did not build or ao. GAS-EA.SYSTEM- 4.00
Prove for purpose at the
OV ER 4 IEA.)
❑ 1,as owner of the 1-� BUILDING USE
Property he exclusively contracting with INDUSTRIAL WASTE INTER. RES IND
licensed contractors[od tD construct the pricens(Sec. does.Business 20.00 CON O OQr
and Professions Code who
builder's License Law does not apply LAWN SPRINKLERS- 1 INC5 V.S. ❑ ❑ ❑
to t owner of Proh projec who builds or improves thereon,and who 5.00
contacts for suchprnjeLwjthacoal ac'-Oil licensed pursuant to LAWN SPRINKLERS-OVER S(EA.) ASSESSORS PARCEL NO.
the Contractor's License Law. 1.00 '
❑ lam exempt under Sec. SEWER-SANITARY-STORM EA.200ft/8.00
reamn .B.&P.C.for this TRACT NO. PARCEL NO.
Owner WATER HEATER W/VENT 400
Date WATER SYSTEM
WORKERS'COMPENSATION DECLARATION 4.00
I hereb WATER TREATING EQUIP, ACC.PATE ACC.FILE NO,
y affirm that 1 have a certi Ncate of consent to self-insure, 4.00
co a cendicata of Workers'Compensation Insurance,or a certified
'OPY therco $e'
O Policy No.a�(r.?L��p/+r7 1 �.O/Y� a�sit /
ZONING ENG.SITE NO.
❑ Certilled copy is hereby furnished.
Z Z ❑ Cerant l �qt�{ file with city,4jp:pection division.
O APPivunt•/✓//lq !llIJJ FIRESPRINK ENERGY T.24
MISC.- REFER TO ORD.
CL W CE:RTIEICC MOF SATI ION FROM WORKERS' PERMIT ISSUANCE Y❑ N❑
LLQ COMPENSATION INSURANCE v ❑ N❑
C PLG,CONTR. B'00 FLOOD ZONE
2hundred
(This section need not be completed if the permit is for one
LIC NO. A L C
h ndr Jdollars IS 1001 or less.l PLG'
U O 1 certify that In the performance of the work for which this
per TOTAL y
U. F mit is isss ed.I shall not employ an PM M Ue' "^x+"•�`- v", .:{yyr..T` w WN.
❑ N
Q w he oma suncel to the Workers'Com�r'hn in any manner so as toMECNANICAL PERMIT e Y � ty Y❑
N❑
ELL Date pensatipnUwsofCali(Preia 3 x - '""' .e 'pE�
Applicant - -a'.A Yv{'Ls'.n$p„"�
} W YOTICFi TO APPLICANT: If,after making this Certificate of Ex- v^sw $5YKv,
Z ALTER OR ADD TO MECH. 4.00 BUILDING 3/G
I- — sunpton.You should become subject to the Worken'Compensation
V su�hlprov siosions lne for thkle bpegntor s ha l u most f rthwith comply with APPLIANCE -
4'00 PLAN CHECK
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(TO 10A00CF.M) 3.00 FEE Z0S f�
I hereby affirm that there is a construction lending agency(or AIR HANDLING UNIT(OVER tOpOpQF.M.) 5,00
the Performance of the work for which this EXHAUST HOOD (WITH DUCT) SEISMIC FEE a Z7
3092 Civ.C.1. Permit is issued(Sec. 2 DO
Lender's Name HEATING UNIT(TO 100,000 B.T.U.) 4.Op MICROFILM
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50
I rmatio that I have read this application and state that the above ELECTRIC
information n correct I agree to comply with all cit VENTILATION FAN (SINGLE) 3.00
ordinances and state laws relating to building construction nand 13(
hereby authorize representatives of this city to enter upon the COMP(3 H.P,or 100,000 B.T.U.) 4,00 PLUMBING
above-mentioned Property for inspection purposes. BOILER-COM-
(We) agree to Save, (Over 1 W,Opp BTUI SEE FEE SCH.
Cupertino ins,judgments
and keep harmless the City of MISC.- MECHANICAL
P against liabilities,judgments, Costs and expenses which REFER TO ORD.
gr yting I th s Pera[ roe against sai City in consequence of the PERMIT ISSUANCE
3.00 CONST.TAX
Satu .51 MECH.CONT LIC.NO. MECH,
' rc of Applicanf�Contrac[or /
Date TOTAL
OFFICE COPY