14780 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES'- USE BALL POINT PEN ONLY ^'
BUILDING PROJECT IDENTIFICATION .. '7 ' +' a PERMIT NUMBER y"'1
4 BUILDING q n � APPLICATION &PERMIT
2-�� QJ SYN ' S.l.!"1C. _(7/ud• BUILDING—ELECTRICAL.PLUMBING,-MECHANICAL " --� 41 SOS'
OWNER'S - PLAN CHECK VALIDATION
"A QTY. ELECTRIC PERMIT - FEE '
Ct
NAME CONTRACTORS t
NAME - UTCETS'=SWITCHES-RECEP 10.00/100 •I +
YMdl o, 317,86 LIGHTING FIXTURES 10.00/1.00 _
ro"rnacrons 4r L APPLIANCES RESIDENTIAL 4.00
• AONREss �Ax ppm'
PHONE j5 PANELS IO.00 DATE OF APPLICATION
ARCHITECT - - - PLAN CHECK FEE N.C.NO.
OR
- PANELS (OVER 200 AMP)' 20.00 ..
INC, EER �c^ 3I7
(Q( c.?'1'I uc.No. 8r0o Is TRANS. _ •3.00 _
ADDRESS
ARCH.ORENG. SPECIAL CIRCUIT 6,00 PERMIT VALIDATION
Zip, EMP.METER OR POLE INS. '
i.20.00 - r w� �.•V GG� .
APPucSsT MOTORS. ' ,SEE FEE SCH. f,'•
ADDRESS, S
• - � SERVICE CHANGE - 20.00 '
O
oLICENSED CONTRACTORS DECLARATION '
' a U U I,hemby affini. Ihal I am licensed under provisions of Chapter 1) ISSUANCE DATE +
zw
G
(Lonunencmg wllli SuUion 70001 0l Division 3 ofthe Buslntss"anA BLDG. .ELECT. PLG MECH.
H z Proftsseons CoJ and n tore is m full for a fy t i
Z o m - Llcens•Cla�ssLc L¢.Number/-[217_Sd_
rvf
@ z w• Dute '1 1 '-1_L Contractor
a m f,� .•.h" BUILDING PERMIT
5 ar 5 a OWNER-BUILDER DECLARATION 'INFORMATION
I ten affirm MISC.- REFER•TO.ORD
w ; LL hereby y a fi m Ihul I am txumpt Isom the Cnntrne[or s License
v VALUATION S/,
HuoJ, ' Law lorthe follor countywhihrequiTesopeprin wrensProfessions ,PERMIT ISSUANCE 10.00 ".-
Qy�+ CDdr.Anycitynr countywhiny structure permitmmnsmance.also '
Q¢ p• imprzwe,demolish,or repair any sROelure.priorm its issuance.also ELEC.CONTR. - LIC.NO.- ELEC. '
D n: requires the applicant for such Permit to file a signed statement that _ TOTAL PERMIT TO -
a. w m he is licensed pursuant to the provisions of the Contractor's License .
. at Law(Chapter 9(cuwntencingwith Section 7000)ctDivision 3 of tbo -
4 o Business and Professions Code)or that he is excmpl therefrom and QTV. PLUMBING PERMIT' FEE'-;
' 2 I-m the basis for the alleged exemption.Any violation ol'Section 7031.5 - STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN IEA:) 5.00
of not more than five hundred dollars($500y): '
❑ 1,as owner of the property,or toy employees with wages us BACK F LOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not - OCC.GROUP. RES.UNITS
into ided or offered for sale (Sec. 7044, Business and Profession, DRAINS-FLOOR,ROOF,AREA,COND 5.00 -Cad,: File Contractor's License:Law does not apply to an"net of +
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP • 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE1
himself or through his own employees,provided that such improve- - -
' •' meets are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00 ,
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4'IEA) I. 200
builder w
ill have the harden of proving that he did net build or in . . .
n. BUILDING USE _
prove fns purpose of Sept.). INDUSTRIAL WASTE INTER. 30:00 RES IND CON PR Dmn, -
❑ L as owner of the properly,am, rlpsivcly contracting with ❑ ❑ ❑` ❑ ❑
licensed contractor, to construct the project(Sec. 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 SPRINKLERS-.OVER 5 MA.) 1.00
contracts for such projects with a cmrtractorts)'licensed pursuant to SEWER-SANITARY-STORM+ the Contmeton's LieCn,n Law. - TRACT NO, PARCEL NO.
❑ •I um exempt tinder Sec. ,B,&P.C.for this WATER HEATER W/VENT ' 6.00
fea)(m a•
Owner _ Date WATER SYSTEM 5.00 ACr,.oppAT''E ACC.FILE NO.
WORKBRS'COMPtSNSATION DECLARATION WATER TREATING EQUIP. 5.00
I II rthyutfirm that
or 1 haven rnsalioe oft Ientnce,tIself6ribie, a A�011NGe ), JENG SITE NO.
+
or a c loica le of Workers'Comp oral Toil Insurance,ora ctrl(fwd ��
tot Y Iheregf�(Sec 3H0f�,Lub.0) � 1 D ' / +
Policy Nolified copy is hereby
Q. ❑ ertilied copy is hereby famished. NK ENERGY T�Y4
Z'Z �Certified c Is f1e with the city inspectiou'division.
O pApmeant 6�1 LyyQ� misc.- - REFER TO ORD. ' y ❑ N❑
rA CI RTIIcICA'I'fi of:F:%BMP 'P
'I'IONROM WORKfiRS' PERMIT,ISSUANCE - ,10,00 (' 4 FLOOD ZONE "A.L.U.C.; .'
W > CO?71'ENSATION INSURANCIi PLG,CONTR. LIC.IN PLG. y❑ N❑ Y❑•:N❑
� Z (This section need AL
not be completed if the permit is for one TOT .'
hundred dollars(S 100)or less.) -
U O 1 certify that in the performance of the work for which this pts- QTV.- MECHANICAL PERMIT•, -FEE • FEE SUMMARY
LL F mil is'issued,I shall not employ any,parson in any Sennett m us m -
U . hcconn subject to the WoUsers'Conlpu nsadcn Lawn of Colifomiw - {
'Ua BUILDING
can
D:du Applit ALTER OR ADD TO MECH. 5.00
} 0NOTICE TO APPLICANT: If,idler making this Certificate of Ex-
empl ion,you should become subject to the Workers'Compensation APPLIANCE - 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall bt Jcemed rcvakcA. AIR HANDLING UNIT(TO'10=C.F.M.) :6,86 -
CONS'1'RUCTIONLENDING AGENCY' . AIR HANDLING UNIT(OVER IOOOOGEM.) 6.00 SEISMIC FEE
. I hereby affirm that IIIre is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5,00
the performance of the work for which this Permit is issued 1Se,c. 'MICROFILM
3097,Cie.C.). HEATING UNIT(TO 100,000 B.T.U.). 8.00
Lender's Name HEATI NG UN IT 00,000 B.T.U.)9.50 Leader',Address 'ELECTRIC'
I miatio t is COT VCI rc'agree cep plication and all
that d county VENTILATION FAN (SINGLE) " 4.00
inl'orenaion is correct. ]'agree to comply with all city and county 9 •PLUMBING/•i - '
ordinances and slate laws relating to building construction, and BOILER-CCNv1P13H.P.or 100,000 B.T.U.).6:00 +
• hereby authorize representatives of this city to enter upon the ',BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. 'MECHANICAL~ 4.••,
ahovu-mentioned property for inspection purposes. E
- (We) agree to save, indemnify and keep hnnnpess the.City of MISC. `REFEWTO ORD. '-
Cupertino against Iiabilitiee,•judgments;coals and expenses'whiel, a I}O q 1 O 'CONST.TAX
may in anyway accrue against said-City in consequence Of tilt PERMIT,ISSUANCE L _
grantingthis per It.' • MECH.CONT. LIG N0. MOTECALH. . -
T "
i n TOTAL40'
Signature of Applicari4}Con(Tactor s Date
OFFICE COPY 17
• - r