09823"'` APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
BUILDING PROJECT IDENTIFICATION APPLICATION 11 PERMIT
a;D!,HIN6 09823
PUNHESs
�7 � I G � O�f J�G�S Gi�IL BUILDING ELECTRICAL PLUMBING MECHANICAL
OWNERS /' ( 7 1„ - ;; •'! - rP tl l,._ y PLAN CHECK VALIDATION
""� DTV. •.`^i ,ELECTRIChPERMIT In t,-.w -ft FEE;'
1/ PHONE • 'y.' a.; [.y if,'�Wa:PG .'r>i:�;"Y.:
cONTRACTORs i^'17ifFU(a UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
HC.NO.'-/5 zD7 LIGHTING FIXTURES 10,00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADOREss �['
3yf �LQ�d✓61 PHONE � � PANELS 10.00 PATE OF APPLICATION
' ARCHITECT
PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
' Sac.NO, SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP ITEMP.METER OR POLE INS. 20.00 - -
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
O a
Ic O o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
aU u I hereby,Minn Ilial I and licenmd underprovisions of Chaplet') ISSUANCE PATE
r a w ('commencing with Section 7(X0)of Division 3 of rhe Business and BLDG. ELECT. PLG. MECH.
r
'En Professions Co -_a ty licelue is in full for'- Wit efeeV�q ❑ ❑ El
ons a'cm'e lass Lic.Number _07
z Y o Dat' U -' Contracror_I_ f._17LWAn .
Y s ..,r, ,."BUILDING PERMIT,,:y�Pr `
rtw OWNER-BUILDER DECLARATION - ANFORMATION j,`.;
LL m I herebyoffum that I am exempt from the Contract-!s License MISC.- - REFER TO ORD
g p Business and l'mfcssions 7VALUATION S/FT,
LL O e Law for the following reason.(Sec.7031.5, PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to consvuc"alter,
S Q 2O' improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC 0 ELEC.
O o requires the applicant fur such permit to file a signed statement that TOTAL PERMIT TO
Wm he is licensed pursuant to the pruvisions-ladle Contractors License Y
w 0> Law(Chapter 9(commencing with Section 7000)ol Division 3 W the h 7 , LUHe/a��i"
a Business and Pru&ssions Code)or that the is exempt ihea(rom and %, .`PLUMBING PERMITi tr1'-7 FEE a''
r$ the basis for tic alleged exemption.Any violation of Scctum 703 i.5 "\ ' STORIES TYPE CONSTR.
w. by anyapplicunt Icor a permit subjects the applicanitoacivilpnwlty ALTER-DRAIN -WATER (EAJ 5.00
of not more than five hundred dollars($5001.1:
❑ I,as owner of the property,or fly employees with wages as I BACK FLOW PROTECT.DEVICE 4.00 ,00 60c.GROUP HES.UNITS
their sole compensation,will do the work,and the structure is Hot
intended or offered for sale IS". 7044, Business and Profesimis DRAINS-FLOOR,ROOF,AREA,COND. 5.00 Zos"
Cade:The Contractor's License Law does not apply to an owner Of /
properly who builds or improves Iheranh,and who docs Mlmh work + FIXTURES-PER TRAP 5.00 "!(A SQ FT,FLOOR AREA TOTALACREAGE
himself or through his ownenmloyLcs,provided that such improve GAS-EA.SVSTEM-11NC.4 OUTLETS 6.00
coI s areot nimended or offered for sale.If,however,the building
n improvement is sold within one year of completion,the owner- GAS•EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
^�1 uilder will have the burden of proving that he did not build or ins- RES IND CON PB OW.,
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 El ❑ 1:1 ❑ 1:1D I,as owner or the property,am exclusively Contracting with
t eemed contractors 10 construct the project tSec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLE 5(EA.) 1.00
contracts for Weil projects with a conlracforl sl tic envd Punuunl lin
the Contractor',License L.W. SEWER-SANITAR -STORM EA,. Oft/10.00 0 pld TRACT NO. PARCEL NO.
❑ Iam exempt under See. ,B.&P.C.for this WATER HEATE VF Z 6.00 A,00
reason
Owner Date WATER SVSTE 5.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TR EATI ' I$\Ip 5.00
I hereby affirm that I have is certificate of consent to sell-insure, ZONING ENG.SITE NO.
ora tertif¢am of Workers'Compensation Instuar",or a cenificd
copy thercof(See 3800,Lub.C.1�
Policy No-
0
oConhpannY 1-124_i"s^uwl�L,�/,�jf•�/s'I
-0 ❑ Cerulmd copy is hereby(unhnhed. FIRE SPRINK ENERGY T 24
Z Z ❑ Ceni(yQ. copy fdvd will the city inspection division. MISC.- REFER TO ORD. V❑ N❑ V ❑ N❑
APPlicanf_ISI�-1.V 5-N ��
~ u! �- �(Ull y��7 PERMIT ISSUANCE 10.00 /O, O FLOOD 20NE A.L.u.c.
CIiRTIPICCOM COMPENSATION
OIW'URKIi KS'
Lu >_ COMPENSATION INSUItANCIi PL CONTTHH, LIC.NO. q PLG. 0,l
CL o (This section need nut be completed if file permit is to, one IL L IIJt r 07y TOTAL f�', ,pV Y❑ IN Y ❑ N❑
2 hundred doll or.IS 100)or lose) - `s': -
U 0 I certify that in the performance of the work for which this pct CITY. MECHANICAL PERMIT ''.FEE., '',( FEE SUMMARY
U_ P nut is issued,I shat[not employ any person in any manner so as to
0U become subject to fileWorkers'Compesution Laws of California. - BUILDING
LEEDate Applicant ALTER OR ADD TO MECH. 5.00
C. NOTICE TO APPLICANT: It,site,making this Certificate of Gx-
Z enhption,you should become subject to the Workers'CmnPensxtion APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must torlhwilh comply will, FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M,) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p000F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the wuhk for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC -
Lender's Address
I Certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 N,
information is correct. I agree o comply with all city soil county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
AlLoolin"C"'
and slut' laws rrlating to building construction, and
hereby out"'rife representatives of this city to enter upon the BOILER-COMP (Ova,100,000BTUISEE FEESCH. MECHANICAL
-1 above-mentioned property for inspection purposes.
(We) agree to save. indemnify and keep harn.less the City el MISC.- REFER TO ORD.
Cupertino against liabilities,judgnlvnis, Costs mW ex senses which CONST.TAX
may n any way 'rue u•'' Said City in "patequence of life
PERMIT ISSUANCE 10.00
gr ng o(Ihisi n it MECH.CONT. LIC.NO. MECH. ,
-rA_ TGTAL TOTAL'.
Sigroture of ApplicanVContractor Date
OFFICE COPY