13075 �.1PPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIF I CATION PERMITNUMBER
BUILDING APPLICATION & PERMIT
• goDREss
BUILDING -
ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S 13075
NAME ` - ' - PLAN CHECK VALIDATION
OTY. ELECTRIC PERMIT FEE
PHONE elL )
CONTRACTOR'S
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
DE� LJ / 3•�( uc.ry �,�,�` LIGHTING FIXTURES 10.00/1.00
ADDRESS CTO WS q ���
CONTRA �Ci/1,. ..SU �yj-j/,.[:o�A,7> PPLIANCES-RESIDENTIAL 4.00
m�;s (r/ I�'+E,3 ; ti L PANELS 10.00 DATE OF APPLICATION
ARCHITIl CT '� /
PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
AENG. LIC,NO. SIGNS TRANS. 3,00
ADONDREESS55 SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
2 r
0
oo o LICENSED CONTRACTORS UBCLA RATION
ri w 1 hereby affirm that I and licensed under provision of Chapter 9 ISSUANCE DATE
V,4 a (eonlnu'neing with Section 7000)ul Uivisi.n 3 ul'the ISuaincas and BLDG. ELECT. PLG. MECH.
r N i Professions Code and)yy hceroe is in lull fu�ry5�1', ���kJe11�L:-
z O m - License Class `.'3 Es: Lic.Number �Rt� ❑ ❑ r1 ❑
R n r
Date�y_�- fir._._Contract.,- -•v✓•✓�✓ Ij�J
a if f
.e. if, OWNIi N/'_ BUILDING PERMIT
w R-BUILDER DISCLARATIO INFORMATION
W ;u N I hereby affirm (hal I and exempt from the Cominew'a License MISC.- REFER TO ORD
u_ o4 Lew for Ile following reason,(Sec,7031.5,Bisimssand Polfcmic. PERMIT ISSUANCE VALUATION S7FT.
Code:Any city or comity which reLuires a 10.00
I '^>P Penoito its mance, IJV, ILE C.CONT 1I. LIC.NO.
Q Q Q D Illlpinve,denlOhfh,or regal!Jlly aHat'Iae,prior IV Ila lasllantt',Ja. ELEC.
o UP E u requires the aPpliczn(for such permit to file a signed HWennnt Ula, TOTAL
a w m he is licensed pursuant to it"Provisions VI'Ihr C.ntracor's Liana, vERMIT TO
Z a Law(C'triple,9(cola mencing wish Section 70001.1 He,i ion 3 of t U, 71L J
Business and Prufessi.rn Code)or That he is e.rnlpl Iif... m and OTY. PLUMBING PERMIT FEE r" L7
a H m an
the basis for the alleged excnm,iun.Any violation nl Sect ion 70J L5
,L3 � by y applicant for a permit subjects IlSTORIES TYPE CONSTII.a applicant oaCPil penally ALTER-DRAIN -WATER IEA.) 5.00
.f not more Ilan0500).1
five hundred dollar,
❑ I,as owner of the property,or my employees with wage)°s BACK FLOW PROTECT. DEVICE 4.00
Illei,sole cirri ensalin U will do the won k.and (hr'bo'lo"n no OCC.GROUP HES.UNITS
intended or offered for sale (Sec 7044, Buaine,, and 1•rulra.iws DRAINS-FLOOR, ROOF,AREA,COND. 5.00
Code:'I'tie Contractor's license Law dors not apply to at,uwocr ul
^" properly Who bold)ln'Inlpicoea III,,.Vll,and Whudoes wrll ,o,k FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AHLA TOTAL ACREAGE
himselfor through his own employees,Provided Oat cUCll impruvr-
'�l� menus are nal intended or,lfered Ivor sale it,haweaer,Ills building GAS-EA.SYSTEM-I INCA OUTLETS 6.00
or ilopo venwnt is sold wil HIT One year of C.mplrti... Ibc uwncr
G builder will have the burden id proving that he did not build or inn- GAS-EA.SYSTEM-OVER 2.00
Prove for puq,.se.f sale.), Bu)DING USE
INDUSTRIAL WASTE INTE . 30.00 RES BUD CON PB Omer
❑ I,us owner of 0m In.Party,and reclusively cow nmtic,with ❑ ❑ ❑ ❑ ❑
licensed conlruc(.n I. construe( the Project ISa'r.7044,Idmin.es LAWN SPRINKLERS-1 I 0'�S V. 1-0;00
and Prufcssioro Code:T'he Contractors Lirrnae Law does nut'apply '�'� ASSESSORS PARCEL NO.
to un own.,of progeny who builAs.r inlpr rues thnmu,and who LAWN SPRINKLERS-OAGER'6 IEA.1 1 0
contracts for such Projects with'a enn(ractorw licensed Punuanl to
unr Contractor's License Law. "P
R-SANITARY-STOR (\,.! BRU 4O' TRACT NO. PARCEL NO.
❑ tum exempt alder Sur. ,Il.eil',C'.lin lllis
reason WATER HEATER W/VEN 6.00
Owner Uan' WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
N'ORKERS'COMPHNSA"PION NECLARA'I JON WATER TREATING EQUIP, 5.00
1 her.by arion Ila, I lase a emit irate of close...w xll-inwn•,
or a certificate of Worked Culnpenswion Insurance,VI a.Crlil'i.d ZONING ENG.SITE NO.
ropy thin rf Src.3800,Lub.('.1_,
r.R N 'j��y�fc.Inpally.Jl
0 fl C,eru'F 'rpy slln.•by tun bed.
,\k�'�, FIRE SPRINK ENERGY T-24
Z 0 I_l,L;.ero L'O,pY Ia Illelf 'illi ' '4 l'ilY Ilnpt'x11Vr1 di\'Ia1Vl1. Y ❑ N❑ Y ❑ N❑
F- O •\pPhcwn r/ MISC. - REFER TO ORD.
� N C[RI'IF'ICA 11:OI'E.CEMPIION FROM NVRKEIt S' PERMIT ISSUANCE 10.00 1 (,. FLOOD ZONE A.L.uc.
LU -_ COSIIT MATION INSURANCE P G._CONTH LIC.NO. I.G.P
0. aZ
This xaion need nal be Couplrn•J it 0m Permit is liar of L-/Rye.• �' /7j ! t�' TOTAL / -v CI� Y❑ N❑ Y ❑ N❑
U 0 hundred dollars 1510(11 ur lea., -
I certify nla,h ter' r nipinantt.f Om work tin wllicll this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is iasueJ,I shall nal engdoY v1Y Penn in any Ina nner so as m
Ow become subject(.life Wurkcrs'C'onlprnsatiun Laws ul Call.nim.
A Nam ICANIApplicant ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE TO ,V'I'LI('AN h: II',)flet making Hlis Q'niflnmC.1 lis-
I- 2 emp(ion,You should become subject to the N'urk.'rs'C'nnlPcnauliun APPLIANCE 5.00 PLAN CHECK
U suchnprovisions for th s permit Shall be dec ned revolod`amply wr,h AIR HANDLING UNIT(TO 10 FEE
,000 C.F.M.1 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=1C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construc,iun lending agency lin' EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued ISec.
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name
Lender'sAddresa HEATINGUNIT(O VER100,000B.T.U.)9.50 ELECTRIC
Ic.nify the,lhuverrad(hisapplicalion and a are(la the above VENTILATION FAN (SINGLE) 4.00 ��
information is correct. I agree (o comply will all city and county PLUMBING Vs-/��l
i.
ordinances and gate laws relating m building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
�. hereby aullmriae represenatives of this city to enter upon are BOILER-COMP (Over ID0,000 BTu
abovcmmntioned Pop,H,furies prainn pugwses. I SEE FEE SCH. MECHANICAL
(We) agree no ave, indenoil')' and keep burn.less (le City VI MISC.- REFER TO ORD.
Cupertino against liabilities, pubelnam., c.a(s and
cxpvn.ms Which
nay n any way accrue against said City in wnscyucncc of the PERMIT ISSUANCE 10.00 CONST.TAX
gr h g Ilia pe/roll. I MECn.CONT. LIC.NU. MECH.
fi. �'+nflrur! 6 ZQ�
TOTAL TOTAL
S" rr ol'APP
Date
OFFICE COPY