11683 APPLFCANT TO FILL IN•INFOP- 1TION WITHIN RED LINES —„USE Bf' POINT PEN ONLY- .
BUI LD1 NG PROJECT I DENTI FICAT _ . PERMIT NUMBER
r GQ! APPLICATION & PERMIT
A E��ryO C�, BUILDING —ELECTRICAL—PLUMBING—MECHANICAL 11 683
OwNEP'a' PLAN CHECK VALIDATION-
NNME CITY. ELECTRIC PERMIT FEE /(� 2
N14Z • CA/�6 PHONE /I��a ✓�,J
NAMERAc7DRsOVIC71Ea_tUTLETS=SWITCHES-RECEP 10.00/1.00
uc.eo. LIGHTING FIXTURES '10.00/1.00 ,lo / 9
ADDRESS ORs APPLIANCES-RESIDENTIAL I 4.00 ,a1. /�O
PHONE PANELS - .10.00 Q — ! DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP)- 20.00 PLAN CHECK FEE P.C.NO.
OR
.
ENGINEER
LIC.No. SIGNS TRANS. - 3.00
AARCH.08
DDRESS SPECIAL SPECIAL CIRCUIT - 5,00 PERMIT VAL 7Lgf�
iIP EMP.METER OR POLE INS. •� �Y
ADDRESS MOTORS SEE FEE SCH.
ADGRE55
' SERVICE CHANGE 0C /a���/y�d{y��{I�sAy._C, .-i
woo LICENSED CONTRACTORS DECLARATION IGIPy�I �rrrUArtIOO
I herebyfromthat 1 am licensed under provisions of ClmPter 9 - ISSUAN/CE'DATE
(Commencing with Section 7000)of Division 3 of the Business and
¢N _ BLDG. ELECT
F o z Professions Code,and my license is in full force and effect. . PLG. I MECH.
o 0 H W License Class ,Lic.Number ®`
Date Contractor
BUILDING PERMIT
¢ ¢w¢ OWNER-BUILDER DECLARATION INFORMATION
MISC.— REFER TO ORD
X 3 LL o I hereby affirm that 1 am exempt from the Contractor's License VAL ATION $/FT.
F .. Oa Law Isar the following reason.(Sec.703,15,Businessund Professions PERMIT ISSUANCE 10.00 Q
Code:Any city or county which requires a permit to construct,alter, -
Q .O
Q ¢ 0 Improve,demolish,or repair any structure,prior 10 Its Illl
aanCC,also ELEC.CONTE. LIC.N0. ELEC. I.
G w requires the applicant for such permit to file a signed statement use TOTAL S.Z �pFaJM T TD
n w m u he is licensed Pursuant(commencing the provisions of the Contractor's License s
Hzthe
a Busiessand Prosionsode)or Section 7s exempt
D therefrom
and
Business olid heaps ed exemption.
Or that IIC Is exempt ectior0111 and CITY. ' PLUMBING PERMIT FEE
¢ the any
applicant Cm the alleged exemption.Any violation ttoa cion malty STORIES TYPE CONSTR.-
i ;� by anyurethan for five permit subjectsthe$5000.licant toacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more owner
five hundred dollars(my em):
❑ I,as owner of the property,or my em with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is nal - - OCC.GROUP RES.UNITS
7 intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 5.00 •�-3_
Cade:The Contractor's License Law does not apply to an owner of
\ property who builds m improves thereon,and who dors such work —FIXTURES-PER TRAP 5.00S Sl.FT.FLOOR AREA TOTALACREAGE
himself or Ihmagh his own employees,provided that such improve
' meats are not intended or offered for our.If,however,too building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is said within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4(EA.) 2.00 77
builder will have the burden arproving that Ile did not build or int- BUILDING USE
pr for purpose of sale.). I INDUSTRIAL WASTE INTER. 30.00 IND CON PB Other'
t 1,as owner of the property,am exclusively Coulacling Willi - ❑ ❑ ❑ ❑
licensed'contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ABSESSORgPARCELNO.-
and Poificasians Code:The Contractor's License Law does not apply
to an owner of property who builds or improves Olereon,and who LAWN SPRINKLERS- EA.) 1.00 3�a —�a _ ops—
contracts for such projects wilh u conlmctol(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00/Q
life Contracris License Law. - TRACT NO. PARCEL NO.
❑ lam exempt order Sec..,R&P.C.for this
reason WATER HEATER Nll � IL;) 6.00
Owner _ _ _ Date WATER SYSTEM 5.00 ,-,V ACC.DATE ACC.FILE NO.
WORKERS'CONIP17NSA'I'[ON DECLARATION WATER TREATIN �jn0 5.00
I hereby affirm that I have a certificate of consent to self-into«, ZONING
or a certificate of Workers'Compensation Insurance,or a-certified ENG.SITE NO.
copy thereof(Sec.3800,Lah,C.). a:U
Policy No. Company _
0 ❑ Certified copy islicreby furnished, FIRE SPRINK ENERGY T-24
-Z Z ❑ 'Certified copy is filed wills the city inspection division.
MISC.- REFER TO ORD.
O Applicant - V❑ N❑ Y ❑: N❑
CC rn PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. -
DU CISRTIPICA'1'EOp EA IiIONANN'FROMWORKIiRS' L7
W COMPIiNSATION.INSURANCL' PLG.CONTE, LIC.NO. PLO.
CL O (Phis sectioni need not he completed if Ille permit is for one TOTAL �!oP Y❑ N❑ Y,❑ N❑.
'::I` Z hundred dollars IS 100)or less.) a��.
0 O I certify,that in the perfonuance oI'the work for which this per- CITY. MECHANICAL PLIZA'1— FEE FEE SUMMARY
W I. mil is issued 1 shall not employ any person in any manner so as to
V became subject to the Workers'Compensation Laws of California. 1
y Date Applicant ALTER OR ADD TO s 19%;() BUILDING �J /IT1
} W NOTICE TO APPLICANT': If,after making this Certificate of Ex-
F Z caption,you should become subject to the Workers'Conrmaation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT IT 11RB . 0
CONSTRUCTION LENDING AGENCY. AIR HANDLING UNIT(OVER 1OPMC.RM.) 600 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
3h09 ,47Nrc once of the work for which this permit is issued(Sec. HEATING UNIT(TO 160,000 B.T.U.) 8.00 MICROFILM
Lender's Name HEATING UNIT IOV ER-100,000 8.T-U.19.50
Lender's Address - ELECTRIC /3011
)9 i
I Certify that 1 have read Has application and sloe that the abovY VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and count PLUMBING (D
ordinances and stmt lues elating In building consttuctiml, and BOILER-COMP(3 HP.6r 100,0008.T.U.1 6.00
hereby authorize representatives ec This city r enter upon 'Be BOILER-COMP Over 100,000 BTU)SEE FEE SCH: MECHANICAL 3.5—��
abovo-ntchlianed property.for Inspection purposes.
(We)-agree'to-save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments,costs and expenses which / CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10:00,f d T( -
grar g of is pe alit. • -' /�/ MECH.CONT.• - - LIC.NO. MECH. t w �r
TOTAL J TOTAL 'y J
Si arc of App(cant/Contracmr Date O/ '—
OFFICECOPY '