6810 APILICANT TO FILL IN INFORMATION WITHIN RED LINES ,. USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
PERMIT NUMBER
ADRUmc APPLICATION & PERMIT;
ADRRES . 6810 O 1 O,
S ' BUILDING-ELECTRICAL-PLUMBING-MECHANICAL �r/l�(D I
PLAN CHECK VALIDATION '( "
i� "TME . _ DTV. ELECTRIC PERMIT FEE `
RONE
CONTRACTOR'S
NAME „I &OUTLETS-SWITCHES-RECEP 5.00/1.00 3,11 _
Eic.No. 7 G/D LIGHTING FIXTURES " 5.00/1.00 ' 2,6
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00 -
ADDRESS C-
r Q . ',J �5T } PHON ` �a- r� PANELS, 5.00 DO DATE OF APPLICATION
ARCHITECT - PLAN CHECK FEE P.C.NO. A"
OR - - - - SIGNS 6.00
ENGINEER -
uc.NO. SIGNS TRANS.. 3.00
ARCH.OR ENG.. - PERMIT VAI DATION
ADDRESS
' ^' ?'a SPECIAL CIRCUIT '5.00
ilvl EMP.METER OR POLE INS. 15.00
.APPuc SS
ADOREss - t MOTORS SE SCH.
' ,
' - S 5:� SERVICE CHANGE 10.00 -
H LICCNSED CON'T'RACTORS DECLARATION, prfinb '
u U rl hereby affirm that I am Iicensedamderprovisionsof Claap(er9, '7s VA S - ISSUANCE DATE
H rt y,. Iconvnenc ing with Section 7000)of Division 3 of(he Business....d - BLDG. ELECT. PLG. MECH.
H o�z I 1 sons Code, d my Imense n m f II foryec.•� d fteyl. ({�'�. eL s .-r Q.
22 _W,"1 CI s LCNumber/Y 7''�X� 9, *, 9-.a�r�, /-s fs,. od ^ ❑ - � - ❑ ❑
o R Dal Cont aU r ` , '
a x E .• 6-1
/$ :/,f' p 'BUILDING PERMIT
¢ a OWNF,R IMIILULR DECLARATION -
o a o r - INFORMATION
x 3 0< I h reby allinn that I nm exempt from the Comrictors Luc MISC.- REFER TO ORD
ao¢ Law for the lidlowmg reason.(Sec.7031.5,Businessand Professions VALUATION
L- y'WJ Code:Any city or county whichrequiresa Permit mCDRxRuCl,alteq PERMIT ISSUANCE " 6.00
ELEC.CONTE LIC.NO.
¢ ¢a p improve,demolish,or repair any structure,prior to its issuance,also EL 4J' y -
d wO¢ .requires the applicant for such permit to file a signed statement that _ - •' TOTAL //�lJ - PERMIT TO
m he is licensed pursuant Iii the provisions of the Contractor's License
'R Z¢ Luw(Chapler 9(commcncing wish Section 7000)of Division3of the - I : �L.EGT
4 0 llusiness'and Professions Code)or tbal-he is exempt therefrom and OTY. PLUMBING PERMIT - FEE
¢ F ca the hosts for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
u ;m by any applicant for a permit subjects the applicant to a civil penalty- ALTER-DRAIN&VENT-WATER.IEA.I 4.00 -
of not more than five hundred dollars(8500).): r ,
'❑ L-as owner of the property,onmy cmploycessvith.wages•as, BACK FLOW'PROTECT. DEVICE ,' 2.00 - Oce:GRODP RES.UNITS
their sale compensation,will do the work,andthe structure is not
intended or offered for he(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of -
a A property who builds or improves thereon,and who does such work. FIXTURES?PER TRAP- - 4.00 so.FT.FLooR AREA TOTAL ACREAGE
himself or through his own emplayces,�provided Ilett such improve;. - - ,
nlanls are not intended or offered for sale.If,however,the building GAS:EA.SYSTEM-1"I NC.4 OUTLETS '4.00 '
- or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
prove for purpose ofsale.).' INDUSTRIAL-WASTE INTER. 20.00 RES IND CON PB Omer
. ❑.. I,as owner of the property,and exclusively contracting with - ❑ ❑. El ❑ , ❑
licensed'Contractors to construct the project(Sec.7044;Runiness' LAWNISPRINKLERS' 1 INC'5 V.B. 5.00 gssEssaes PARCEL NO.
and Professions Code:11iL Contractor's license law does not apply
to an owner of property who builds or improves thereon:and who LAWN SPRINKLERS-OVER 5(EA.) im
contracts fur such projects with a contractors)licensedputsuant to - '
Orc Coexempt
w.,License la
SEWER-SANITARY-STORM EA:200ft/8.00 TRACT NO. PARCEL NO.
l am
❑ lam exempt under sec:•.... ' 1II!&P.C:I'nr this WATER,HEATER W/VENT 4.00
Owner' Dhie WATER SYSTEM ,4.00 ACC.DATE - ACD.FILE NO.
WORKERS'COMPENSAT'ION DECLARATION WATER TREATING EQUIP. 4.00 ,
I hereby alfirm`flam l have z cedilicaleof,amsenttosdf-insure - ` ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a ci ruibi d
'Copy thereof(Sec.3800.labCJ.' !
Policy No.-Company (
O' .._ '• ❑ Certificdeo yisbembY rnished. C7 _ �Ct//o� FIRE SPA INK ENERGV.T 24
Z Z' A+•CcRifted' Y'iv I• [h Ore.cityi c- ' ivision: MISC.- REFER TO ORD.
Q �ppllCanl•. i Yo- N Y ❑ 'N�
I1N CER 'II:KATE OPE 1iMPTIO OMW RKERS' (PERMIT ISSUANCE 6.00 -FLOOD ZONE A.L.UC.
LU COMPENSATION IN, RANCE, . (• PLG.CONTE. _ LIC.NO. PLG.
G' O P '1 thissection cSd-Bof be compldedhf the pC mil 'Ro,mic' - TAL
, TOV.� N� V ryo
� Z hundred dollars($100)or less)'• U -: ,( U O' 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY '
LL U mit is issued, I shall not employrany person in any manner An,as to
become subject o the Workesi Campenwtinn Laws dGalifornid.
O w t
Doc- - e llcan( n - - - BUILDING -
a. 1 p . ALTER OR ADD^TO MECN. 4.00 -
} m NOTICE TO APPI:ICANI: If,after making this CCudicale of I:x- -
F Z emptinn,Yen should become subject to the Workeri Compensmicm 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 10AM C.RM) 3.00
r 'CONSTRUCTION LENDING AGENCY'•+ AIR HANDLING UNIT(OVER 10,00DGflM:) 5.00 SEISMIC FEE
x•^I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
IIS performance of the work for which(his permit is issued(Sec. MICROFILM
3097,Civ.C.L -, "HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's N:uno- HEATING UNIT(OVER 100,000 B.T.U.)7.50 9a3 Sz
Lcndera Name s' - - ELECTRIC "1
I certify that I have read this application and state that thenhorc ' VENTILATION FAN (SINGLE) 3.00 '
information is correct I agree to comply with all city and county PLUMBING '
ordinances,.and state laws relating to building,constmetion, and BOILER-COMP(3 H.P.or 100,000B.T.U.) 4.00
hereby authoritompr"unlatives of flirt" ity'to enter,upon'Ibe BOILER-CO MP:*Yo 100,606 BTU(SEE FEE SCH. MECHANICAL--
ahuv6meationedproperty for inspersion purposes, '
(We) agree to rave;•indemnify and kev,'Imonless the City of MISC:- - REFER TO ORD. -
Cupertino against liabilities,judgments, costs and expenses which a -ISSUANCE _ 3.00, CONST.TAX
.r may;in ny way ue agnins[ said City in Consequence al'[he a' 1
ni ti f Ibis rc mit.
j' MECN.CONT. 4• LIC.NO. ,v, MECH.
;-.1 rorgL TOTAL
S nature of A p1i ant/ act - , Date n '• -
. "t.. _ 4_ OFFICE COPY.
1 ,.1 e.