8190 ' .. , I .` t '" " "FUnIYIH I IUrN VVI I HIN HED LINES - USF BALL POINT PEN ONLY
9UI LDI NG PROJECT I DENTI .TION PERMIT NUMBER
ADDRESS APPLICATION & PERMIT -
ADDRESS /
:21'�/p �T�6r/S ��� �/ BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 819 0
OWNER 9
NAME•-�
Ory " PLAN CHECK VALIDATION
C ,Q1 PRONE " ELECTRIC PERMIT -«,.�- _-FLEE!,NAME
C�� �I UTLETS-SWITCHES-RECEP19c99/1.00 9m
7• 616 LID,NO3S3-z7C/ OOLIGHTING FIXTURES 1,00
COryiRRCTOR'S
AOOREss�srei4S PPLIANCES-RESIDENTIAL 4.00D2 S3 PHONES, /` 2p7/
PANELS 10.00
ARCHITECT DATE OF APPLICATION
ENGINEER
OR PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE C.NO.
ARCH.OR ENO. L.C.No, SIGNS TRANS. 3.00
ADDRESS SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zIP EMP. METER OR POLE INS. 20.00
APPLICANT'S
AOOREss MOTORS SEE FEE SCH.
o2
SERVICE CHANGE 20.00
0
o O LICENSED CONTRAC DECLARATION TEMP.POLE ' 30.00
a i w I hereby affirm that I am licensed nxd under provisions of Chapter 9
¢ n (commencing wish Section 7000)of Division 3 of the Business and • ISSUANCE DATE
HwN Professions Cod,.�'pdm li[ense is in full for and Pf(ect BLDG. ELECT. PLG. MECH.
z O m Livens Class�f - Lic.Number I ❑ ❑ ❑
9 w F Date �= Contractor ? - C
¢ a F / /
2 ¢ w OWNER-BUILDER DECLARATION City Of CU BUIL INO'PERMIT
w ;' H 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO RD INFORMATION,
F c_ o j Law for the following reason.(Sec.7031.5.Business and Professions - PERMIT ISSUANCE VALUATION $/FT.
fw � Code:Any city or county which requires permit towns[ruL9,almc -1909'
ce ¢ o improve,demolish,or repair any structure.prior to its issuance.also ELEC.CONTR. LIC.NO. _
O ec requires the applicant for such permit to file a signed statement that ELEC. ! _
n w he is licensed pursuant to the provisions of the Contractors License TOTAL 3 S
riQLaw(Chapter 9(commencing with Section 7000)of Division 3 o RhPERMIT TOe LL�Y_7
Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT, '� ,FEE:1'' / a
¢ m the basis for the alleged exemption.Any violation of Section]031.5
La ; by any applicant for a Permit subjects the applicant to a civil penalty " _ STORIES TYPE CONSTR.
of not more than five hundred dollars(5500).1 ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ I,as owner of the property.or my employees with wages as
their sole compensation,will do the work,and the structure is not BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
intended or offered for sale ISec. 7044, Business and Professions
Code: The Contractor's License Law does not apply n an owner esson' DRAINS-FLOOR,ROOF,AREA,COND. 5.00
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP
himself or through ho Own employees,provided that Such Improve- 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
meats are not intended or offered for sale.If however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner
builder will have the burden of proving that he did not build or im. GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BU LONG USE
Prove for purpose of sale.).
❑ I,as owner of the property. INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
p party,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors od to construct the priced ISec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
and Professions Code:The Contractor's License Law does not apply ASSESSORS PARCEL NO.
co an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor)sl licensed pursuant to
the Contractor's License Law, SEWER-SAN ITAR V-STORM EA.200ft/10.00
❑ I am exempt under Sec. .B.&BC,for this TRACT N0. PARCEL N0.
reason - WATER HEATER W/VENT 6.00
Owner Dam
WATER SYSTEM 5.00
WORK ER$'COMPEN$ATION DECLARATION ACL.DATE ACC FLLE NO.
1 hereby affirm that I have a certificate of consent to sof-insure, WATER TREATING EQUIP, 5,00
Xor A Certificate of Workers'Compensation Insurance,or a certified ZONING
copy thereof(Sec.3800,Lab.C.). ENG.SITE NO.
Policy No. Company/� C.- 41C f�'1.Sj7
O ❑ Certified cop is hereby furnishe0 '-
Z Z X Certified y Is files) ( t y i pection division. FIRESPRINK ENERGY T.24
F O Applicant �' MISC.- REFER TO ORD, Y N v NE]
y C'FRTIFIC'ATI'.OF EXEMPTION FROM WORKERS' .PERMIT ISSUANCE 10.00
Lu > COMPENSATION INSURANCE FLOOD ZONE A.L.U.C.
d O _ PLG.CONTR. LIC NO. PLG.
(Thio section need not be completed if the permit is for one TOTAL V❑ N� Y E] IN
U O hundred dollars IS 100)or less.)
I certify that in the performance of the work for which this per. - - -
1L U mit r is issued,I shall not employ any person in any manner so as to QW' - MECHANICAL P.ERMIT'.- :rr 1 FEEI'C- 'i°kEIIUMMARY -I
O WU become subject to ole Workers'Compensation Laws of California.
Date BUILDING
} t°ia NOTICE TO APPLICANT nIf,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
2
elliptical,you should become subject to the Workers'Compensation APPLIANCE
ProvU suchlp proof visions nsthe Labor or this permit shalde l be deemed revoked.ou must forthwith omply with AIR HANDLING UNIT(TO 10 5.00 PLAN CHECK
AODQF.MI 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER l0,000QFM.I 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec.
3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC- -
I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
i-foram tion is "it"',
orrect I agree to comply with all city and county
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or100,000B.T.U.) 6.00 PLUMBING
hereby authorize representatives of this city to enter upon the
above-me-tinned property for inspection purposes. BOI LER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which
may in a y way accrue against said City I consequence of the PERMIT ISSUANCE 10.00 CONST.TAX
granhn f this permit.
/ � �j MECH.CONT, LIC.NO. MECH.
�Kl+c'S' TOTAL
$,gnatni •„ppmprtt/Lntraetor Date TOTAL
OFFICE COPY