7117 Y APPLICANT TO FILL IN INFORMATION WITHINrREU.LINES4 USE BALL POINT PEN ONLY "
V + -. PERMIT NUMBER
BUI LDI NG PROJECT']DENTI FICATION k ex- s
OUR-DING
- • „_ APPLICATIONS& PERMITt
'�, •^a BUILDING ELECTRICAL PLUMBING.--MECHANICAL
9 OWNER' n'uv—(
_ PLAN CHECK VALIDATION
NAME / TV: _ S^ELECTRICTERMIT .^ .,,A FEE" ,
" . x
CON R CTOA'
NONOUTLETS, SWITCHES-RECEP 5.00/1 00 - a ,
L,C.mo - L�� LIGHTING FIXTURES 5.00/1.00 CONYT '
i
ACTOR$ PPLIANCES-RESIDENTIAL 4.00ADDRESS
`
PHON ;PANELS'-;: 5.00 - '- DATEOFAPPLICATION
-
ARCHITEcl a q".^ 4s PLAN CHECK FEE P C NO
OR 't• '- 'k SIGNS +' 6.00
x
ENG I ...�" era '...
�9! LIC.NO -A t SIGNS TRANS. 3.00 a '"
,ARCH,
OR ENG. - - .i PERMIT VALIDATION
A Ess V 'P a`.'� IS CIRCUIT '500 „
�f3 dPou r3
EMP METER OR POLE INS , . 15.00
APPLICANT'S ,y( _ r > /
.. o MOTORS ` SEE FEE SCH
- �df `_ 'Vl( ' SERVICE CHANGE ^1000
k' �O¢ O 13 y 'LICENSED CONTRACTORS DECL RATION
I'h•pcby Iifiirin that I aim licensed under provisions of Cha'pt r).-,7T,` ,,
ISSUANCE DAT
(Commmm ing with Section 7000) f Division-3 of the Business and' ¢ - BL I ELECT. PLO. MECH.
I r (casinos Code,and my license a in full force and effect _ "•')
.z o w- LienseCh.,,l 'lac Number. -
0 z r- w DatL Contractor" g'„ 4 '
' ¢ p•wa OWNER-BUILDER DEC ZION (' - -f " a .AU DING PERMIT
U,
MISC k` . REFER.TO ORD `.i'( NFpRMATION f
x 3 ` .• I hereby alfa that I am,exempt from^the Contr actor Licensec VALUATION $/FT.
LL.
0 j' 1 w Hittite fallowing r ao .(Sec.7031 5,Bus ne sand Professions - 6 00
PERMIT M IT ISSUANCE
Code..4nyctyor or ty hick regmresapermt(nonsuanc aper, '• �®
Q ¢ ¢ o - liprov demolish o[repai any st[uctum,prior its issuance;also ELEC CONTE LIC NO - ELEC. nm
CitY q1 0 k -quires the applicant far such permit to file a signed statement that ' TOTAL
w m he Is,liceesed'pursuant to the provisions of the Contractor's License p RMI TO,_
Law(Chapter 9(emmmenciug with Section 7000)of Division 3 of the _ .. ,
- a ,Business and Professions Code)or that he is exempt therefrom and OTY.x,. M1PLUMBING PERMIT
• ¢I-c, the basis for the alleged exemption.Any violation of Section 7031.5 - - 'STORIES I TYPE CONSTR.
say applicant for apermit subjects,the applicant to a civil penalty, ALTER;DRAIN&VENT-WATER'(EA:) 4.00
of nut more than five hundred dollars($5008.)
I,as owner of the pioperty,or m`y employees with wages as ' t BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP HES.UNITS
their sole.coriiponsalion,will do the work,and the structure is not _ r
intended or offered for sale(Sce. 7044, Business and Professions `-+ DRAINS-FLOOR,ROOF;AR EA,COND. 4.00
Code:T h"Cont actors License Law dos not apply to an owner of -
properly who Il ddb r r lilt proves lectern,and who does such work FIXTURES-PER TRAP '} 4.00 SQ FT.FLOOR AREA TOTAL ACREAGE
hunsuit or thro gb I rc own employes prow dad that such impro e - x' -
irntsare 'otintendedoroffered for sale if,however,the building 'GAS-EA.SYSTEM:VINC.4 OUTLETS 400
• '
or upprovementis sold within one year ofcompletion,the owner -- GAS'-EA:SYSTEM=OV ER 4(EA.) 1.00 Buaolry USE
builder will havetheburden of proving that he did of build or.im - RES IND C PB ,Omer
prove for.purpose of. Ie.) - INDUSTRIAL`WASTE INTER.`- 20.00 '
as owner r f the propety,em exclusively contracting wioi - ❑' .❑ Y,, ❑ ❑
licensed,contractors In construct the projecLt Sou 7044,Business " LAWN*SPR IN KLERS-J INC 5 V.B. ' 5.00 - q&&Es5oR5 PARCEL NO.
and Professions Code:The Contractor's License1jov does not apply -
u
it)a owner of property'wliohips nr;improves thereo "ind who LAWN SPR INKLERS-OVER 5(EA.) 1.00 ^
contracts far such i prole ts with contrsctnHJ iiccnsed pursump to " - ' '- -9VER
' -
the Con trector'sL' s 'L w.�; •'.,,., SEWER=SANITARY-STORM EA.200ft/8.00 - TRACT NO PARCEL NO.
`'�• - ❑ I in exempt made,See: B&1 C Tof thus - -
r 'reason '_ - t. WATER HEATER W/VENT 4,00
• 'Own-r Dut - - `�1, " WATER SYSTEM 4:00. ACC.DATE ACO.FILE NO,
rWONKI:RS'COM PENSATION DE-IARATION ° � T - !' WATER'TREATING,EQUIP. ' '4.00 •' '
I hereby affirm that I have a cctlifm ne of ononil to tlf insure '
or a certificate of Workers'Compensation Insurance it a certified 4 20NING ENG.SITE NO.
Te cupy thereof(Sec 3800 Lab.C) s ,r- :
Pof cY No t r Cconpauy
- _❑ Cerffied,copy is hereby famished x. (IRE SPR INK ENERGY Td4
Z ❑ Certll iud Copy i';tiled rtl the,City*Inspection division -
s ,O 'Applicant , fl ' MISC , ' ` REFER TO ORD. v❑ _ N❑ Y ❑ N❑
~ ,rP ERMIT ISSUANCE 6.00
cc rn CI RI IEICATE OE I XEMPTION PROM WORKERS FLOOD ZONE' A L.u.C.
_'.LU ° COMPP NSA TION INS URANCE, s, 5 PLG CONTH LIC.No. PLG.
(This - -
CL section need be completed thepeml for- n TOTAL �❑ vN❑ ',Yy❑N ,•N❑
'•� Z. hundred dollars(S 100) .less.) 'a • "
U O 1 certify that,in li e-pedorman'n of'me work for which this pc,-' QTY. •• MECHANICAL PERMIT FEES '"FEE+SI)MMARV''t I
U F mit Is issued;I'shall amLemy p
ploy anerson io any manner seas to
y.._,O w he m subject to llm WorkcW Compensation Laws ,f Calif....ii + ' - '
,Dat `•- - Applicant - '' - a BUILDING
} to NOTICE '10 APPLICANT:,If,after making,thls Ccrtifiwte Of,hx- ALTER OR ADD TO MECH. 4.00
F Z eml lima,you.should become subject loathe Warkus Compensation S, gpPLIANCE ' 4.00 PLAN CHECK
,Provso
isions of the Labor-Code you must forthwith 'oniply wi0, 1`
C.6 such provisions or this permit shall be deem d'revnkCd.F '_ ' AIR HANDLING UNIT(TO 10,000 _F.M.) 3.00 FEE .
CONSTRUCTION LENDING AGENCY 'AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE S'�s
I hereby affirn ❑it Bier,Isa onstru'tionleid "y'agencyfr EXHAUST HOOD`(WITH'DUCT) 200 -
the performance of the work,t r which-thi{perni t is issued(Sen MICROFILM:'
3097 `I cJ. 1a,;,i HEATING UNIT(TO 100,000.B.T.U.) 460
Lender's Nam,"
HEATING UNIT 100,000B.T.U.)7.50
'lender's Adtlress - HE _ �ELECTRIC
C v I certify that I have read this application and state that the above VENTILATION FANI(SINGLE) •r - ' 3:00 -
Information is Correct I ugrce.to comply with all city aitd,Lutcuty 'PLUMBING
ordinances and state laws relating to building wnsVuclion and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 400
hereby authorize representatives,of this city-,to enter,:upon the r�•," BOILER-COMP(Over 100,000 BTU)SEE FEE SCH MECHANICAL
above-mentioned propertyjfoi inspection Purposes - - '
e-
(We) 'aSree=to save, indemnify and keepiha'mless file City oil MISC.- REFER TO ORD. -
Cupertino against liabilities;judgments, ciists and'expenseswhch CplsJ$T,TAX
ma ariy,way accrue agai said City,inconsequence,of the PERMIT ISSUANCE 3 DO
h gOf( ' pe " ECR.CONT LIC.NO. MECH .� o.
A}
'. TDTAL TOTAL
Signaterec plicam/Contract rPate,
x r. OFFICE COPY ' _ - '