6297 'APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY ,
BUILDING PROJECT IDENTIFICATION - PERMIT NUMBER
BUILDING -APPLICATION & PERMIT ^^
AD n s _ _ b G
97
B ILDING-ELECTRICAL•-PLUMBING-:MECHANICAL
Do, EH'S - PLAN CHECK VALIDATION
NAM OTY. ELECTRIC PERMIT FEE
PHONE
Ni ACTUHS OUTLETS-SWITCHES'-'R ECEP 5.00/1,00
NAME T
�IMA 1 ON 11C.No t16307 LIGHTING FIXTURES 5.00/1.00
f,ONTRAcronS APPLIANCES-RESIDENTIAL 4.00
ADDRESS�'•a r
7i !� S ti Qr/1 _OII� - DATE OF APPLICATION'
x
s / PHONE
PANELS S.00
I ARCHITECT SIGNS 6,00 - !PLAN CHECK FEE P.C.NO.
OR
'ENGINEfn , tI -
LIC.No. .� SIGNS TRANS. 3.00
AARCHDDREOR SS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION zip EMP.METER OR POLE INS. „ 15.00 OC A�,^
APPLICANT s MOTORS 's.. ' SEE FEE SCH. pVV
SERVICE CHANGE 10.00 11,90 0
F o o LICENSED CONTRA(-TORS DECLARATION - 01 A �V
1 U w I hereby ufllrm that I am licensed under pro rs n5 of Chapter 9 - - U'0 AN4CE DATE
�� (L rinang will,Section 7000) f Division 3 01 the Business W BLDG. E PLG. M H
r o z Pr fcssons Co an m ,cense s n f 11 fu_Se anyL c'^ - ❑ ❑
zo m - it Lns Clasx CO*
1 N mh r 12 }4313 L-eya-
o Dat -I<) o f actor.-_CLIMIZ !J -
a • BUILDING PERMIT
c o a _ OWNER-Bmu)I a DFCLARA'rION - - INFORMATION
K ; I- I hereby affirm that I am exempt from the Contractor's 1-iccnse _ MISC.- REFER TO ORD
wLLo¢ law for the following reason.(See.7031.5,Busim,i,cmdlTresions
PERMIT ISSUANCE vnwnnoN
0 'Code:Any city orcounty whicbreyuiresapeimitioconslrucf,alter;, - � - 6.00' ,
QQ¢ � improve,demolish,or repair any structure,prior to its issuance,also ELEC'CONTR. - . LIC.NO. ELEC.
u w m LL reaches the applicant torsuci permit to Idea signed'itmemeiit ilial, - TOTAL PERMIT TO n
he is licensed pursuant to the provisions of the Contractor's License
HiQ Law(Chapter 9(comnencingwith Section 7000)of Division 3o fine
i o Business and Professions Code)or Thal,he is exempt therefrom and CITY. PLUMBING PERMIT FEE
(cI- m the basis for thealleged exemption:Any violation of Section 7031,5+ .• STORIE TYPE CONSTR.
a 3 .- by any applicant for a permit subjects the applicant ma civil penalty . ALTER-DRAIN -WATER (EA.) 4.00
.
of not more than five hundred dollars(5500).1: .11 - - -
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 200 OCC.GROUP RES.UNITS
'their sole cm mensatio.,will do the work,and'the structure is nob . -
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
'Code:I'lie Comonchir's,License Law does nal apply to an owner b1:
property who builds or naproves theMoll,and who does such w0 k " FIXTURES-PER TRAP , 4.00 SO.FT,FLOOR'AREA TOTAL ACREAGE,
himself or through his own employees provided that such improve-'-
)x� ments are not intended or offered for sale IL however•the budding '1 GAS-EA.SYSTEM-1INC.4OUTLETS 4,00 -
of
unprovemem Is sold within one year of comph.lion the owner, GAS-EA.SYSTEM-OVER 4 IEA.) 1,00 BUILDING USE
bullder will have the harden of proving that he did not bmld'or IDI- .
move far purpose of saleJ. , RES- IND 'CON PB OiM1er
.❑ L asowner ol'the propertyfa,ii exclusively contractin'gwilh' ' INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑ ❑
licensed cmaractors to constrtmt 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 dnurn"or apply_' "'
to an owner of properly who builds or improves'tlfcomm,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
'contracts for such projects with a contractor(s)licensed pursuant to -
'the Contractor's License Law. SEWER-SANITARY-STORM EA.200f1/8.00 . TRACT NO. 2 PAHCELNO.
❑ Iumexempt.under Sec: ',B.&PC.for this WATER HEATER W/VENT 4,00 .
reason
Owner _ 'Ume. - WATER SYSTEM - 4.00 ACC.DATE ACC.FILE N0.
WORK ERS'COMPENSAPION DECLARATION - WATER TREATING EQUIP, 4.00 -
,x I hereby affirm,that I have a certificate of conseni to sPEmsurc„ ,f -- _ - ZONING
or a certificate of Workers"Compensation Insurance,or certified, ' ENG.SITE NO.
r(tty,thereof(Seu 3800,Lah,C.).
.Policy No Company
O' CIC (died copy is hereby furnished, . FIRE SPRINK ENERGY T-24
Z z ertified copy Is filed wilh'Ble city inspec0on'divlsion. MISC.- REFER TO ORD.
O Apic
p arl V ❑ N❑ V❑ N❑
~ rn PERMIT ISSUANCE .• 6.00 FLOOD ZONE A.L.U.C.
s CF.RTIFICA'1'17017 EXEMPTION FROM WORKERS'
LU �- •." - COMPENSA'r ION INSURANCE',. - i, PLG.CONTR, LIC.NO, IF
-
0 Z (This section nerd not,be completed if the Permit is for pie TOTAL Y❑ N❑ Y❑ N❑
(This
dollma($100)or less.) ' -
.. U O ,'I certify that-in the perfannance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE'SUMMARY
LL H Grit is issued,I']fall not employ any person in any manner so as to
U become subject In the Workers'Compenmlion Laws of California.
U Q. 'Date - Applicant - - ALTER OR ADD TO MECH. 4.00 r�t
DING
} ED NO ITCI.,FO APPLICANT?If,aftermakingthis CertiEculI,of fix-
F" Z emplion;you should become subject to IheWorkers'Compensation qpp LIANCE 4.00 CHECK,
provisions,of the Labor Code, you must forthwith comply with uch pmvisionS or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=13-F.M-) 3.00CONS'IRUCI'ION LIiNDING'AGIiNCy AIR HANDLING UNIT(OVER.10 OWC.F.M.) 5.00 IC FEE
I hereby affirm that.there isa construction lending agora<y for EXHAUST HOOD(WITH DUdT) 200
the performance of the work for which thi ,permit is issued(SecOFILM
3097,Civ.C.). ,. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Tender's NameIT(OVER 100,000B.T.U.)7.50Lender's Address iTRICaL. ,
ICFHTy)hat Lhave read thisapplicalion and state that theibove VENTILATION FAN (SINGLE)LE) 3.00
namion is correct. I agree to comply with all city,and county PLUMBING
ordinances and state laws relating (0 building`construction, and BOILER-COMP 13 H.P.or 100,000 B.T.U.1 4.00
hereby eulhorio, representatives of this city to enter upon'.1he BOILER-COMP IDvor 100.000 BTU)SEE FEE SCH, MECHANICAL
above mentioned Property for inspection purposes.
(Wc) agree to save. indeinnify and keep harmlessjttic'City of MISC.- R REFER TO ORD. -
- Cupertino against liabilities,judgments, costs and expenses which pERMIT ISSUANCECONST.TAX'
may i, any way accrue against said City in'consey uence of the
• gut ofthis y arc e MECH.CONT. LIC.NO. TOTA MECH. -
o- �' TOTAL
ignature of Applicant Contractor Dale. 7
y - OFFICE COPY