6783 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
• BU I LDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDIADDNG
APPLICATION & PERMIT
O3� f� ' / BUILDING ELECTRICAL PLUMBING—MECHANICAL 6783
NAMER N TY :FIgtl .I I J f p !+ er" � h Ov
PLAN CHECK VALIDATION
PHONE F, . .- + .1'EI-ECTRIC.PERMIT7 '7` t('kq�FEE .
CONTERACTORs UTLETS-SWITCHES-RECEP 5.00/100
NAM
LIC.NO. ILIGHTING FIXTURES 5.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
AOO E55 ,(
aybNE � PANELS 5.00 DATE OF APPLICATION
oNcn,TECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.nO. SIGNS TRANS. 3.00 '
ADDRESS ENG SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zip TEMP.METER OR POLE INS. 15.00
APPLICANTS &LyA& MOTORS SEE FEE SCH.
A RE55
SERVICE CHANGE 10.00 v /
r o D LICENSED CON'I'RAC`I'OHS DECLARATION
a 0 u 1 hereby allinn Out I a,n licensed under muvisious of Chapter 9 ISSUANCE DATE
n a d (EGml.....eing with Section 7000)of DWis,Un 3 of the Business and M
BLDG. ELECT. PLG. ECM.
r w i Professions Cq4�aNy y hcensc u m full fora aryl r fpyl ❑ ❑ ❑ ❑
z o w— Limise Class L-. Jr / Lie Number efU�Il.�
O H Dalt' f ,y:}L,
a Y i a- vc�i�7� C- ( ,? a;$I'BUILDING PERMIT�,M1,,��1-rxF'
5 e, W a OWNER-BUILDER DECLARA'n ON 7"z' l?
0x ° MISC.- REFER TO ORD wy/rr V'rIN FORMATION �e
x 3 u y I hereby aflirm that I an,exempt from the Cant...coif License VALUATION $/FT.
Law for the following rcasun.(Sec.7031.5,limincaund RUfessiuns 6.00
1- - g PERMIT ISSUANCE
y eai2 Cute:Any city nr county x'hich rcquiresapenniuoconvnle t.alma
Q E ¢D Improve,denclish,Or repair any structure',Ilrlor 10 its issuance',also ELEC.CONTH. LIC.NQ ELEC.
i iL m s requires She applicant ant I r Such 1 ern t 10 file a signed slalnnwn that TOTAL PERM( TO
h u liused pursuant to the P.,i,on of D¢Cont.mtur's Lm I
r i Law(Chapter 9( runemm�gw lOSe Urn 7D00)of Wnsia,3 of the - - '
f i o Busum"and PrulLssiun'Code)or that he is exempt Omrefrum and DTV,..-I +1 I ;PLUMBING PERMIT
r m the basis for the alleged exemption.Any vmlalion of Se,wo 7031 5 .t u H f - 'V4` } .+, i i ' .��.,} _ • ,rs ^M, r�;r[• STORIES TYPE CONSTR.
by any applicant far a permit subjects the applicant to a civil penally
ufmmomre than fisc hundred dollars(S500).): ALTER-DRAIN&VENT-WATER (EA.) 4.00
❑ I,as owner of the property,err my employees will,wage,as BACK FLOW PROTECT.DEVICE 2.00 DEC GROUP RES.UNITS
their Sulu compensation,will do the wo,k,and She Amnure is nut
intended err uttered fur sal (Sec. 7044, Businen and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Cude:The Contractor' Lic use Law dues not apply m an owner ut
property who buil n roves thereon,and who dues such work FIXTURES-PER TRAP 4.00 SOFT.FLOOHAREA TOTALACREAGE
,• himself or tlool. n emPlmyeas,Providad Ilut w.h improve
G unts are nuts mnsu ruflcrcJ for sole.Ih howeveq rho huilJing GAS-EA.SYSTEM-I INC.4 OUTLETS 4,00
or iupravrrn. s n d within One Year Uf completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
IT will h n 1 uNen ul proving that he did not build or int- HES IND CON P6 Ona,
for pyRlms of sole.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner 01 tile property.am exclusively'cuntmclingwith ❑ ❑ ❑ ❑ ❑
licensed cummctors Inc construct the projca(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:I'he(contractor i License Law don nut apply
to an owner of property who builds or improves thereat.and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contmas for such projects with a emdructorts)licensed pursuum to
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I nm except under Sic
rcuwn ,B.SBC.tar this WATER HEATER W/VENT 4.00
Owncr Dam WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
h WORK ERS'COMPENSATGN DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure,
err a certificate of Wurkeri Cunt
me""' Insurxnec•,or a cendo,d] ZONING ENG,SITE NO.
copy Ihercof l See.18Q0,Lu BC s
Policy No._ /�Prnpau
0 ❑ Ce'lilie opy beret umished. FIRESPHINK ENERGY T 24
_Z 2 'fL Cenifis. is tiled with th< city inspaclion division.0 Applied MISC.- REFER TO ORD. y ❑ IN v ❑ N❑
~ re, PERMIT ISSUANCE 6.00
Uj — CIiRT114CATliPE I AX K) TIFROM WORKERS' FLOOD ZONE A.LU.C.
CL COS71not be completed
i PLG.CONTR. LIC.No. TPLC
OTAL Y❑ N❑ Y❑ N❑
1 O (This suction need not be emnplertd if ter• permit is for one
-:) 2 hundred dollars($I UO)or less.)
U O 1 certify that In the performance of file work for which this per. QTY. y, " 4W, +s,, 1 's `::FEE SUMMARY
F nal is issued,1 shall not ens to an person ut an manner so us t ,M CH I SAL PERMIT 'f ! FEE(.
LL p Y Y P'ser Y + i
Q become subject am the Wurkeri Compensation Laws of CeldurnU. is'YA•' s +- � "I t r x•'1,1„
0 a Dale Applicant - BUILDING
>_ in NOTICE TO APPLICANT: II',arta making this Certificate of six- ALTER OR ADD TO MECH. 4.00
2 empl ion,you should become ser 'cel m the Workers Compensmint APPLIANCE ,4.00 PLAN CHECK
provisions of the Labor Code, ou must forthwith comply with FEE
U such provisions or this permit sh' I be deemed revoked AIR HANDLING UNIT(TO 10,0ODC.F.M.) •3.00
ell sfRU, I LENDING AGENCY AIR HANDLING UNIT(OVER 10 ,8M.15.00 -'n- SEISMIC FEE
I hereby air nn hal h re is a cmtstrudiml lending agency for EXHAUST HOOD(WITH DUCT) '2.00
the performance o om ark for which this permit is issued IScc. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 S ..U.) 4,A
Lenders Name - _ H EATING UNIT 100,000 .T. .17: ELECTRIC
Lender's Addr
I certify tilt have readlllisapplicutionandstnte ib,,,b above VENTILATION FAN (SINGLE) 3.00
inform on c rrect. I agree to comply with all city and county PLUMBING
mrdinaif
s d same laws relating to building construction, and BOILER-COMP(3 H.P.0r 100,000 B.T.U.) 4.00
Q• erey a ori,, representatives of this city la en aur upon the BOILER-COMP (Over 10.000 BTU)SEE FEE SCH.
above-mentioned property for inspection purposes. MECHANICAL
(We) agree to Kate, indemnity and keep harmless Gln City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which 1 CONST.TAX
may ' y ayccrve ainst said City in consequence of the PERMIT ISSUANCE 3.00 /
un n a i per ti . MECH.CONT. LIC.NO. MECH.
,�' TOTAL%�.
Signator u App,cant/COntractur Uu1eNji- r
OFFICE COPY
I ,
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -,USE BALL POINT PEN ONLY
ji. • 'BU I LDING PROJECTI IDENTIFICATION - PERMIT NUMBER
soILDING APPLICATION & PERMIT /�
ADDRESS C 783 O l
BUILDING—ELECTRICAL—PLUMBING—MECHANICAL 6 f of
„ OAMERa ,'`
v
'b`h 1" A p
Akj '1..S ,�. ye` i}�. PLAN CHECK VALIDATION
E -sELE6TI '6RIC' PE?,RMI Ta . , .FEEr
.visDrvE
NOtM1ERacTDR$ OUTLETS-SWITCHES-RECEP 5.00/1.00
_lc.No. LIGHTING FIXTURES 5.00/1.00
CONTRACTOR s - APPLIANCES-RESIDENTIAL 4.00
ADD EES
NE PANELS 5.00 - DATE OF APPLICATION
ARCHITECT - SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00 -
ADD Ess ENG.- • SPECIAL CIRCUIT - 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
` APPLICANTS - MOTORS II SEE FEE SCH. .
A REaa r
J SERVICE CHANGE 10.00 ��,•
00 LICENSED CON-1 RACTORS DECLARATION (/
U I hereby affirm that I am licensed under provisions of Chapter 9 - ISSUANCE DATE
y a N (Commencing with Section 7000)of Division 3 of theQBusiness and BLDG. ELECT. PLG. MECH.
F N P'ofiez Lieenwiots Cggt_x ticcnse is in lull for YL O ❑ ❑ ❑
O o w— License Class S.� Lic..Numbc�`L
g w L w Date '�1 Contractor
a r E �_ iBUILDINGyPEFMIT
wu OWNER-BUILDERDECLARATION '?ll lU INFORIIAATIUN
; I hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD a --
H u o v, Law for the following reason.(Sea 7031.5,Businessand Professions PERMIT ISSUANCE - 6.00 VALUATION - S/FT.
Code:Any city or rounty welch requires a pcnnit to cnnstn.clddter,
<O improve,demolish,or repair any structure,prior to its issuance,also CLEC.CONTR. LIC.NO. ELEC.
D , requires the applicant for such permit to file a signed statement that TOTAL PERM I TO
a w m he Is licensed pursTmnt to the provisions of the Contractor's License ,l
H 2 t
Law(Chapter 9(commencing with Section 7000)of Division 3 of the c ±.'$+ G h✓
4 o Business and Professions Code)or that he Is exempt therefrom and QTY., . -'PLUMBING PERMIT
Ie r m the basis for the alleged exemption.Any violation of Section7031"5k STORIES TYPE CONSTR.
ate _ by anyapplicant tura peril subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not mom than five hundred dollars($500).): -
❑ I,as owner of the property,or my employees Willi wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP qES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for se. (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,CON D. 4.00
Code:The Contractor' Lic ase Law does not apply to an owner of
DR operty WIIO but s O li oves Ihemon,and who does such Work FIXTURES-PER TRAP 4.00 50.FT,FLOOR AREA TOTALACREAGE
'. himself or Through is n employees,provided that such improve- .
meats are roti ten nrffarcd for sale.It,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improveme a within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will h v urden of proving that he did not build or am- RES IND CON PB Omar
prove for osL nfsuleJ' INDUSTRIAL WASTE INTER. 2000
❑ 1,as owner of the property,am exclusively contracting with . ❑ ❑ ❑ 0 0
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
conlesets for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
17 I um exempt under See,—,B.&P.C.lot this WATER HEATER W/VENT 4.00
reason
Owner Dme WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
'1 WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. - '4.00
I hereby affirm that I have a certificate of consent tosell-inter",
ora certificate of Workers Com eklsatii n Insurance.or a certified ZONING ENG.SITE NO.
copy thereof IS, 38 0,Lah.C.
Policy No. epa
00 CCtlit ierrj�,:op ehe. umished. FIRE SPR INK ENERGY T-24_z Z �Certifis•Af 1is tiled with the city inspection division. MISC.- REFER TO ORD.
p Applicant—• Y IN Y ED NE]
~LU CSR'fFICI SION FROM WORKERS' PERMIT ISSUANCE 6.00
FLOOD ZONE A.Lu.C.
LL COMPFNATION
INSURANCE PLC.CONTR. LIC.NO. PLG: Y E] N v
d O f Nis section need not be completed if the permit is for one TOTAL _ - N
Z hundred dollars IS 100)or less.) -
U O 1 certify that in the performance of the Work for which this per- QTY. a .;M 1 AL PERMIT FEE+ .FEE SUMMARV„-y..:�.�,
LL F mit is issued,1 slmll not employ any person in any antnner so as to
O U become subject to Ills Workers Compensation Laws of California: -
y Dale Appli°amt ALTER OR ADD TO MECH. q,pp BUILDING
} W NOTICE*1'0 APPIACAN'I': If,after making this Carrlwate of Ex-
HZ eniplum you shuuW heconm se. 'ccl to the Workers'Compensa(ion APPLIANCE a¢.00 PLAN CHECK
provisims of the Labor Codc, ou must forthwith comply With FEE
C.1 such provisions or this permit sir he deemed revoked. AIR HANDLING UNIT(TO 10,00DGF.M.) 3.00
co STR I LENDING AGENCY AIR HANDLING UNIT(OVER 10 ,P:M.1;5.00 �n('1 SEISMIC FEE
I hereby affirm hat h re is a construction lending agency for EXHAUST HOOD(WITH DUCTI 200 'ova
the ped'ormunce t the ark for which this portent is issued(Sec. - MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B ..U.)
Lender's Name HEATING UNIT 100,000 . .)
Lender's AAdr ELECTRIC
I certify th t have reed this application and state that the above VENTILATION FAN (SINGLE)'' 3.00' F
inform lion c acct. I agree to comply with a.N city and county PLUMBING
oNiran s r d state laws relating to building construction, and BOILER-COMP(3H.P.Dr100,000B.T.U.) 4;00
hereby m .orizC representatives of This city to enter upon the 50
OILER-COMPrIOver t00,IN10 BTUI SEE FEE SCH: MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- - REFERTO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may y ay ccom' ainSt said City in consequence of the
an n i pe i MECH.CONT. , LIC.NO. MECH. O
TOTAL` "P TOTAL'14
Signa La pp.cant/Contractor - Dalehl
OFFICE COPY.