13476 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATION PERMIT rvumeER
nDILDING APPLICATION & PERMIT 13476
ADOREss
�I �A7mVi=NS -^ BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME �{ OTY. ELECTRIC PERMIT 'FEE .
/-V-CQ OIL Cc, PRIOR 7G2 - .
coNTRAcrDR's
NOUTLETS-SWITCHES-RECEP 10.00/1.00
AME p
�Z LIGHTING FIXTURES 10:0871':00 %--
-� roNTRacroas APPLIANCES-RESIDENTIAL 4.00
ADORES, I
36� I PHUNE(�/'S) O-6` PANELS 1D.DU GATE OF APPLICATION
ARCHITECT ^,y r+ 11 PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
DENGINEER Dp-'S /LJ tJ1-�f
G4C " uc.No. SIGNS TRANS. 3.00
ARCH,OR ENO. 5.00 PERMIT VALIDATION
ADDRESS^ tb��� SPECIAL CIRCUIT
,,t ��t'e 4.V•- ZIP(.74Q( EMP.METER OR POLE INS. 20.00
APPLICANT'S LprJU MOTORS SEE FEE SCH. /Vn.^"X,''".--�.,,--✓\
ADDRESS // I ,
Cw(_K leu LSI- W C)WI-1 SERVICE CHANGE 20.00
I f/
Wo o LICENS1 DCON'I'RACfORS DECLARATION
<u U I hereby attain that I and licensed under pmvisiuu,ul Chapter. ISSUANC ❑ATE
(commencing with Section 7000)01 13116ion 3.1 the Bu,inea Wnd BLOG. ELECT, PLG. MECH.
F w Professions Code,'nd my license is in full tome and .11"p1. 7 ❑
Z O m License Class_� p.p Lie.Number/Y/ JLJL_ ❑ ❑ ❑
0 r w Dale-:n=U-/-�-g-Contu,wF+i&ie,;J_L2.Lj-�
P: L s BUILDING PERMIT
¢ I,W a OWNER-BUILDER DECLARATION
0" MISC.- REFER TO ORD INFORMATION
E:
; u N I hereby affirm that 1 um exempt from lite Contractor's Lia•.° VAwATION SIFT.
u
Des Law for the lullowing rcawn.(Sec.7031.5,Itusino,and l'rulemiuns PERMIT ISSUANCE HY.88- /J_ -
� y0 � Code:Any city orc.unly whichrequiresapenniltoeunslrucl,alter,
SC a ¢O improve,demolish,or repair any structure,prior to its ronin,,,also ELEC.CONTR. LIC.NO. ELED. {� V
m LL requires the applicznl for such permit to file a signed statentenl thol TOTA Lp \ PERMIT TO
` w he,s licensed pursuant to the Pr v -, s 01 the Contractor's L eels,
r ¢ a L w(Cn pter 9(commencing withS ton 70001 ID 'full of lits - ❑-• ra /T�r�Jt�e•'�'L
tl sm and I'mlelamns Code)o that lieesetup[Ih r Ironn:md OTY. PLUMBING PERMIT .(FEE
¢ r m the basis for the alleged nhptio A y✓ I'tion 1 S tit 17031.5 - �•`� DRIES TYPE CONSTR.
d ; by any applicum l'xaper.nit Butt cls tit IIIIC nn u . it puml[y ALTER-DRAIN VENT-WATER (EA.) .00 Vn 1•
of not more than five hundred dollars 15500).1:
❑ 1,as owner of the property,or my employees with wage,as BACKFLOW PROTECT. DEV ICE 4. Occ.GROUP RES.UNITS
their sole compensation,will Jo(lie work,'mW tiro structure is nut
intended or offered for sale (Sec. 7044, Business and profess..... DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:.The Contractor's License Luw does not apply loan owner of
property who builds or improves tlmrcon,and wlmdovsmchwurk FIXTURES-PER TRAP 5.00 SD,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided Ilial such inlprose
1 mems are not intended ser offered lin'Sale.It,however,the building GAS-EA.SYSTEM-1 INCA OUTLETS 6.00
improvement is sold within one year of completion,lire owner- GAS-EA.SV STEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will love the burden of proving that he did out build or int- HES IND CON PB Other
.../
proveOur purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
I,as owner of the property,um exclusively con D'acting with ❑ ❑ ❑ ❑ ❑
lie, contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
C professions Code *1 Contractor's License Law does not'apply'
to an owner o1'property who builds or inlproses thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
eontracis for,Itch projects with a sontruetor(s)licensed pursuant 10 SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor i License[-a., TRACT NO, PARCEL NO.
❑ I n -aenlpl 7/e Se 11&P.('.I'll this WATER HEATER W/VENT 6.00
rest.,
Own° D'•'le WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
w
W'ORKISRS'CO 1pIiNSA'RON DE 'L,\RA IION WATER TREATING EQUIP. 5.00
I hereby affirm that I have'4 certificate•of consent t.xil-lu%ure' ZONING ENG.SITE NO.
r a certificate of Workers'Compcnsutio,h Insurunae,or a cer tided
Q ❑ CeRdu•A copy it hereby lurnuhcd, FIRE SPHINK ENERGY T 24
Z 2 ❑ Certifi,yyy� �±±yyY u I tit t • Cap' i ''liun division.
O Applicam�LE.�{L= d'ALZG^✓�-� MISC.- RE FEfl TO ORD. Y ❑ N❑ Y ❑ N❑
= w CERTIFICA1'ICOI7 EXEMPIION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.C.
LU > CONIPi:NSA'I'ION INSURANCE: PLG,CONIH LIC.NO. PLG.
CL O (This vection R,,J not be Completed it the Perini[ I, for ane TOTAL Y[:] N❑ Y ❑ N❑
D 2 hundred dollars IS 1001 it less)
U O 1 eertity that in the puiurriauce of lite work for which Deis p,r- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL H our is:stied,1 shall not c.npluy ally P:Tsui in:my 11,11111c,x1 al to
U become subkct to the N'.rkcri Conlpcn,umn Law,of Celilurnie.
O ou Date, Al,plica,lt ALTER OR ADD TO MECH. 5.00 BUILDING S-� r1Tt
} b NOTICE TO AITLICAKI': It,utter nuking this Certilieute of I.,-
� Z cmptlon,youshould bamme IIH,1e1 to me N'arken'(")"I .,..tion APPLIANCE 5.00 PLAN CHECK
prolsums of the Luber Code, you must forthwith comply with FEE
U such PRwitwo,Or this pernit shall be•decnhed u,,.k,d. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE 3
1 hereby affirm that there is a construction lending agency lot EXHAUST HOOD (WITH DUCT) 5.00
the 3097,Performance
�n.e of the work aur whim ILM
this permit is issued ISvC. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROF
Lender:Na
Lender' me s AJJn' HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC 30
ss
I Certify thmlhave rend this aVPliewiun and,tato lhm tlrc abuse VENTILATION FAN (SINGLE) 4.00
in,,RRaron is correct I agree to Cumply with all city and cmudy PLUMBING
N, � urJins le , and 'tale' laws rulwing to budding comMrumion, and BOILER-COMPI3 H.P.or 100,000 B.T.U.) 6,00
^ hereby amborite representatives of this city [o elver upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-Mentioned property for inspection purpose's.
fWe) agree to %ase, indannify a.d keep harmless III, Cil'of MISC.- REFER TO ORD.
Cupertino aguiml liabilities,judgumms, :.H+ send expanses which CONST.TAX
may iq any w'u1( IF against aid CHtr in consequcnn• of the PERMIT ISSUANCE 10.00
b\ gra trW pl hit lft• it el A V' MECH.CONT. LIC.NO. MECH. If
��yll` /j 1 Q �.(. TOTAL TOTAL
Cigna arc of plicanl/ 'untran. U, ��'�_
OFFICE COPY