6858 APPLICANT.TO FILL IN INFORMATION WITHIN RED LINES` USE BALL POINT PEN ONLY,
BUI LDI NG PROJECT I DENTI FICATION - - 'PERMITNUMBER
BDnp - APPLICATION & PERMIT
Aoor
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL _ 6858
o NEB's •A•, LSC.• - - - - " -
PLAN CHECK VALIDATION
.NAME
*� *43V-11
/ OTY. - ELECTRIC PERMIT FEE
�lJ PHaNE*
CONTRALTON'S - ..
E _ f 'yp OUTLETS-SWITCHES-RECEP 5.00/1.00 •
C _,C.No, oYAJ `/O/ LIGHTING FIXTURES
CONTRACTORS„ - APPLIANCES- - 4.00
ADDRESS '
�'t t PU(iN PANELS 5.00 DATE OF APPLICATION
ARCRITECT PLAN CHECK FEE P.C.NO.
oR•` SIGNS 6.00
'ENGINEEn -
*- LIC.NO. '• SIGNS TRANS. 3.00
AROW OR�ENG:; PERMIT VALIDATION
ADDRESS - SPECIALCIRCUIT '5.00 „ e
- �` ZIP EMP.METER OR POLE INS. 15.00 `
`
APPLICANTS
ADDDRESS MOTORS ' -- SEE FEE SCH.
"9 ) SERVICE CHANGE 10.00
uOF',¢O a .sLICENSED CONTRACTORS DECLA ATION
a u,w.l I hereby affirm that I am licensed all provisions of Chapter 9 -
H a m lore .,an,with Section 7000)of Dmsmn 3 of the Business and 'ISSUANCE DATE
0 z.;• Pr f o sCoJ nn1S liccn 's fdlfort 1 -
BLDG. ELECT. PLG: MECH.
z o Llcenu CI:1I�/ raN tuber O O 0 .
O �F� Uat K Co tctor
a x s - - - ae;�., - BUILDING PERMIT
¢ ¢ a OWNERH UILDIiR DLCLA A - '
A o a U - INFORMATION
X LL y' 1 hereby uffir l that I am exempt from theCnll actor's License .MISC.— REFER TO ORD
al LL O a Law f tile following reason (Sec 7031 5,busmessand Professions pERM1T ISSUANCE VALUATION,,, $/FT.
Code:Any city or county which requires s permit to construct,alter, 6'00
2 ¢ Q Imp' v rl meta! rr 1'ir any tru t Lire,prior to its lssuanc also ELEC.CONTR. - LIG NO. [LEC. "
DLL
requires lh•applicant for Stich permit to Glc a signed statement that TOTAL MIT TO
x h Is.licensed pursuant to the provisions f the Contrectnr s License - ` DPE � '
i.
Law(Chapter 9( ommenemgviil Section 7000)of Dwson3 of the - r -
H a Busmess and Professions Code)or that he isexempt therefrom and CITY. PLUMBING PERMIT FEE
rt �'m ' .he basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a pannit subjects the applicant fon civil penalty
' ol'not more than five hundred dollaiy($500).): ALTER-DRAIN& VENT-WATER (EA.) 4.00
❑ I,as owner of the property,or my employees with wages vs BACK FLOW PROTECT. DEVICE 2.00
their'sole compensation;will do the work,and the structulis not DCC.GROUP RES.UNITS--
intended or offered for sale (Sec. 7044, Business and-Professions • ' DRAINS-FLOOR,ROOF,AREA,COND. 4.00 '
Code',The Cmitnutor's License Law does not apply'(o an owner of -
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP > 'U SD.00 ;�Q.OFT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that,till improve ,
monts cc out moulded or oil.red for otivlf,howcvethe building GAS-EA.SVSTEM-1 4,00 "
or inlpiovemeAt is sold within one yea(of completion,the owner-
builder
wner- GAS-EA.SYSTEM--OVER 4 IEA.1 1.00 BUILDING USE
builder'will have,the hu Nen of proWng that he did not build,)r ire
pnv To ).rpL)'sc )fsole.). / a INDUSTRIAL WASTE INTER. 40.00 RES ,IND CON PB Other
O 'I as owner of the prop ty,a ri exclusively cc,I acting with ❑ ❑" ❑ ❑ .❑
_
licensed contractors to npsi ruct the project(Sec 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. , 5-00 gSSE$SORS PARCEL NO.
and Professions Code":'I'BcrContractor IS License Law does not apply -
to ua owner of atopyy y who huilds or improves thereon,and who LAWN SPRINKLERS-,OVE
and)'Ruts I'or such pfojccis with a contrdclor(sl licenwd pursuant In,
the Contractor' [icenu Law. SEWER-SANITARY-STORM EA.200f1/g.00 Q. ' TRACT NO. PARCEL N0.
❑ )'I sato rept under Sec. ;BAI.C.for this WATER HEATER WIV 1 {4100 "
., reaxon _ 0.
Owner 7 Dale -
',/ WATER SYSTEM '4.00 ' f ACC.DATE ACC:FILE NO,
WORK ERS'COMPF NSA]ION DECLARATION WATER TREATING E Af CUDerfj&PO -
,.
berchya10rm ilial I have arertificaa•ofumum to Self-insure. - - ZONIrvG
m a certil'ilc.ranft�qegif/J yW�orker'Compensation sum ce,nr a cerlifxI ENG:SITE NO.
copy tieIAY p.`V C.1./��j� //J�
Policy
o am sL . ."• "
�• q �-fI iItl p Il creby furdsh - - FIRE SPRINK ENERGY T-24
'Z UJ�Cerlilild I, fi tt [ cit ms cellon-division.
ZO An plican✓✓//'' �`K. y p MISC.-. REFERT_O ORD. Y ❑ N❑ Y'o N❑
PERMIT ISSUANCE ' a
' � CLRTIFICATI. I•IiXI:MITION'PROM WORKERS 'a� + ; I$y.00 /Q,(� FL000
M Q COhIPIiN$Al'ION INSl1RANC v .COfjMIC.NO: TLG
OTAL,
❑ ,❑ ❑- ❑
('['his section need not be completed tithe perm t Is for one VOL// O
Z hundred dollars(S 100)or iesO � -
. U O I certify that in the performane ne�f�tlle work for which this per- CITY .MECHANICAL PERMIT , FEE., FEE SUMMARY
LL U mil is issued,I shall not employ any person in any Iitmlbel so as to . -
hecmne subject In the WCrkcrs'Comperes)ion Laws of Cal_ifornia.'
Da DIIm- p�'APpBcpnl '. ALTER-OR ADD TO MECH. 4.00 BUILDING '
} m NOl'ICE 'f0 LICANI: If,aIle'making this Certificate _ -
F. Z_ clnption u should become subject. Die Workers'Compensation APPLIANCE" . 4.00 PLAN CHECK
provl s of tlIe Lu but Cone yau.must b"Ibwi Ol romRly-witll r
su provisions or this Penni.Shall be deemed revoked.!' AIR HANDLING UNIT,(TO 70,000 C.F:M:) 3.00 FEE
• CONST'R UCTION-LFNDINCAGENCY - AIR HANDLING UNIT(OVER 10=C.EM.) 5.00 SEISMIC FEE
I herchy affirm that theri.is�unstraction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the pe,fo minor of th.w6ik for which this permit is issued(Sec, MICROFILM
3097,Civ.CJ.j HEATING UNIT,(TO 100,000 B.T.U.) 4.00
L der's N. a
Lender'sdr�ress • HEATING UNIT(OVER l00,000B.T.U.P.50 ELECTRIC
L tIfy that I have read Ili s application and state that the abo c VENTILATION FAN (SINGLE) 3.00
Int..nation is correct. I agree to comply with all city and county :BOILER-COMP(3 H.P.Dr 1000008.T.U.) 4'.00 ' PLUMBING
ordinance,and state laws relating .o building construction. and ,
hereby authoritc representatives of this city to enter upon the -,g OILER-COMP IOver 100,000 BTU)SEE,FEE SCH. MECHANICAL
above mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City:of I MISC.-. REFER TO ORD.
Cupertino against Iiahilities,judgments, costs and exp......which ..PERMIT ISSUANCE , _ 3.00 .CONST.TAX
may in y w' 'accrue against said City in consequence,of the' .-
gmnli L.I' perm)). MECH.CONT. LIG NO. MECH.
TOTAL' TOTAL
Signature o APP Ant/Contractor ate I .
� - -
- OFFICE COPY '