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6852 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUd LDI NG PROJECT I DENTI FICATION ADIUIDRESS APPLICATION & PERMIT PERMIT NUMBER pooness l,Q 6852 � n r ^ • o rs z S S(:rUlfMaj�yQ�C'�l/-J�//F BUILDING ELECTRICAL—PLUMBING MECHANICAL 'F� TS h / NAME kwy Ro• ray( A", 3 •" 6VV8V2 PHONE 6TV 'f ayt1xaR y5a.ELECTRIC,PERMIT ,'/-x -,y + k:FEEy PLAN CHECK vAL10ATlory CONLPpCTORS q - p��me+w ji 11 J 1 UTLETS-SWITCHES-RECEP 5.00/1.00 ©vLa. CC LIC.NO, L54g LIGHTING FIXTURES n oosss TOR'Si3[o-Z (Vol✓1 N.+ r 5.00/1.00 APPLIANCES-RESIDENTIAL 4.00 ARCHITECT s 'rJs PANELS 5.00 DErvDINEER SIGNS F APPLICATION GATE O6OG PLAN CHECK FEE P.C.NO. ARCH.ORENG LIC NO. SIGNS TRANS. 3.00 ADDRESS SPECIAL CIRCUIT 5.00 PERMIT VALIDATION APPLICANTS IIP EMP,METER OR POLE INS. 15.00 ADDRESS MOTORS SEE FEE SCH. Da i SERVICE CHANGE 10.00 I 0 0 LICENSED CONTRACTORS DECLARATION or i u I hereby affirm that I am licensed under provisions of Chapter n a'Dmmencing with Section ]000)of Division 3 of the Business and N 2 PA,c"iuns Code,and my license is in full fo�y ( ISSUANCE DATE 2 O w License Class L BLDG. ELECT. P p z D Lic.Number [ LG MECH. m E Dole 11,�Z�-kDE—Contractor ❑ O ❑ E ¢ w. OWNER-BUILDER DECLARATION EUIkDINO E MI 4, A 3 0 H hereby uffinn that I am exempt from the Contractor's License MISC.— REFER TO ORD '0"" i`_SY!IIIF RMA'T1011111- - F u p J Law for(he following reason.(Sec 7031.5,Businessand Professions 1r1"; E IA i' Code AD)city or county which requires apermit loconshuct,nl[eq PERMIT ISSUANCE VALUATION 5/FT. 2 0 O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR, 6,OU DLL requires the applicant for such Permit to file a signed statement that LIC.NO. A w m he is licensed pursuant to the Provisions of the Contractor's License ELEC. F i Law ICha ler9 TOTAL Z a P IwmmenLing with Section]000)ol Division ..A kr i PER MIT TO i D Busmess'I'd Professions Code)or that he is exempt therefrom and DTV. . r y Il^/ a: H m the,basis for the alleged exemption.Any violation of Section 7031 5 '.+3;,`f ',.� l LUMBINQ VERMIT .r`'+"e "REE�'' n 3 _ by any applicant for a permit subjects Me applicant to a c...I Penalty - �,R,a' -x s DRIES of not mora than five hundred dollars4500).1: ALTER-DRAIN& VENT-WATER (EA.14.pp TYPE CONSTR. ❑ has owner of the Property,or my employees with wages az Ihe.r Sole compensator, will do the work.and the structure iz not BACK FLOW PROTECT. DEVICE intended or offered for sole (Sec. 7044, Business and Professions 2'pp OCC.CROUP RES.UNITS • Code:The who builds or License Law does not apply to an owner ol. DRAINS-FLOOR,ROOF,AREA,COND. 4.00 Property who builds or improves thereon,and who does such work FIXTURES-PER TRAP himself or through his own employees,provided that such improve 4.00 nlen[S are not i mended or offered l'orsale.If however,the buildingGAS-EA.SVSTEM- SD.FT.FLOOR AREA TOTAL ACREAGE or improvement is sold within one year of completion,the owner- Prove 1 INC.40UTLETS 4.00 builder will have the burden of proving that he did not build or im, GAS-EA.SYSTEM-OVER 4 (EA.) Prove for purpose of sale.). 1.00 BUILDING USE ❑ I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. REs IN CON PS Omer licensed contractors to construct the Projen 1Sce. 7044,Business 20.00 ❑ ❑ O ❑ ❑ unJ Prolnsionz Code:The Contractors License Law does not apply LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 m an owner R Property who builds or improves thereon,and who ASSESSORS PARCEL NO. coiIU.c(S I'ur such projects with a nnnractoa sl licensed pursuant to LAWN SPRINKLERS-OVER 5 (EA.) 1,00 the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 ❑ I and exempt under Sec. ,B.&P.C.for this TRACT N0. PARCEL NO. r weer ATER HEATER W/VENT Owner 4.00 Uase WATER SYSTEM WOkRIi RS'COMPENSATION DECLARATION 4'00 ACC.DATE ACC.FILE NO. I herebyWATER TREATING EQUIP. 4.00 affirm (hal I have z certificate In consent to sell-insure, or a c he".e to of Workers'Com e/s�at1oR,lns a r ace lifted copy thereof(Sec. Comp00. b,C.l�, t/`/�. ZONING ENG.SITE NO. PolicyCe . Company�[V Z Cl❑ Ce IS NO, furmshed. Z 2 ❑ Ce copy BI the s. inspecti division. O Applicron MISC,- FIRE SPgINK ENERGY T-74 REFER TO ORD. Y o N[] v 0 No w CP:IITIF I, OE IiXEMPT1 N FROM WO E S' PERMIT ISSUANCE LU 0 COMPENSATION 6.00 Q. SUSAN PLC.CONTR. FLOOD ZONE A.L.U.C. � I this lion n ed not be co leted if the Permit is for one LIC NO PLG Z hundred dRlars 151 01 or less.l TOTAL Y V O 1 cerYty(hal in 1 perform' iE,{SL �s - N❑ Y N C3 LL v u II( ' s d, I hell emPf a of the work for which ,Per y persR in an Ian as to — .• -s4�a'•`rMECNANICAL SFEE 6U '4B 1 fC rota 'sk+'in.-^iT r..: . $,s..,.s.''• } n"PEE4x �''F'_.., S. MMARY�,t..';,5" a / 1 PPIi. n e sat a - . .. . / w > 2 `'O' E T APP CAN - ,ager making thus Certificate o X. ALTER OR ADD TO MECH. q,pp BUILDING z IPI on,you should co c bject to the Workers'Compensation APPLIANCE Prosis.oms of the Labor Code, ou must fonhwilh comply with 4.00 PLAN CHECK U such provisions or this emit shit a deemed revoked. AIR HANDLING UNIT(TO 10FEE ,030C.F.M) 3.00 CONS Ut IPON LEN INC AGENCY AIR HANDLING UNIT(OVER 10 1 hereby affirm that there is a constrwmn]endingAOOGFM.) 5.00 SEISMIC FEE the Performance of the work for which this permit isissued'See EXHAUST HOOD(WITH DUCT) 2.00 Land,CIv.C.1. Lender's Name HEATING UNIT(TO 100,000 B.T.U.) 4.GO MICROFILM Lender's Address HEATING UNIT(OVER 100,000 B,T.U-)Z50 I certify that I have read this application and state that the aboveVENTILATION FAN (SINGLE) 3.00 ELECTRIC Information is correct. I agree to Comply with all city and county ordm,rccs and state laws relating to building construction, and COMPI3 H.P.Or 100,000 PLUMBING hen'hy authorize rtpresenlatives of this city to enter upon the BO property for inspection purposes. BOILER-COMP to 100,000-TUI SEE FEE SCH. (We) agree to save, indemnify and keep harmless the City of MISC.- MECHANICAL Cupertino against liabilities, Judgments, cosh and expenses which REFER TO ORD. may in any way accrue against S City in con que a of the PERMIT ISSUANCE CONST.TAX gr got this er it. 3.00 MECH.CONT. LIC.N0. MECH. r TOTAL .`L .-•L' gnamre DI Applicant/Commctor o� a `� TOTdI=e,,; OFFICE COPY