12694 (2) APPLICANT TO FILL IN INFORMATION WITHINRED LINES,- USE BALL POINT PEN,ONLY
f'
�*6I LDI NG PROJECT 1 DENTI FICATION - PERMIT NUMBER
am,Dwc APPLICATION & PERMIT
p ,
e ADO Dsa ,¢isF IDR'��: - . 12694
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OwNL.'S _ PLAN CHECK VALIDATION
" /1/`/1/I {h],/////��� err/`l � 7 r DTV. ELECTRIC PERMIT FEE
/N\ r/ 1L16gf PHONE
NAME AGTOR's UTLETS-SWITCHES-RECEP 10.00/1.00
- LIC.No,. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S APPLIANCES-RESIDENTIAL : 4,00
- ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
RRcurtECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER '
'LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. - P JAyaLIDATION
ADDRESS- n SPECIAL CIRCUIT 5.00 `A'/�nR
ZIP TEMP. METER OR POLE INS. 20.00 O APR
APPLICANTS MOTORS SEE FEE SCH. APR ,2 a 1987
ADDRESS X717
' . SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION,
Ix v C I hereby affirm that 1 am licensed nm der Provisions Of Chapter 9 ISSUANCE DATE
u¢Hi Q w (commencing with Section 7000)of Division 3 Of Ilse Business and BLDG. ELECT. PLG MECH.
H y w Professions Code,and my license is in full force and effect.
Zo 0 m License Class Lie.Number - ,. - ❑
H m E J Dale - 'Contractor'"
¢ Y s BUILDING ERMIT
a a i OWNER-BUILDER DECLARATION. INFORMATION
E:
y I hereby affirm that I-am exempt from the Contractor's License MISC.- REFER TO ORD
u y 0 VALUATION $/FT.
r LL 0 J Law for the following ream.(Sec.7031.5,liusinessand Professions' PERMIT ISSUANCE . . 10.00'
w Code:Any city or county which requimsa permit to construct,altar, '- -
Q Q Q p Improve,demolish,or repair any structure,prior t0 its issuance,also ELEG CONTR.- LIC.NO. ELEC.
- 0 u requires the applicant for such permit In file a signed statement that - TOTAL
e, . he is licensed pursuant to the provisions of the Contractor's License
H i
Law(Chapter 9(eommencing with Section 7000)o(Division 3 ofthe I
f i o Business and Professions Code)or that he is exempt therefrom andQTY. PLUMBING PERMIT FEE
¢I- m the basis for.the alleged exemption.Any violation of Section 7031.5
n g _ by any applicant for a Fermi,subjects the applicant toa civil penalty I
of not more than live hundred dollars 05000.). - - ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do,he work ,and the structure is not ,OCC.GROUP ES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SG.FT.FLOOR AREA TOTAL ACREAGE
\ himself or through his own employees,provided that sucliimprove.
7 meats are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
• q Or improvement is sold within one year of completion,the owner- GAS-EA,SYSTEM-OVER 4(EA.) 2,00
/ builder will have the burden of proving that he did.not build or int- BUILDING USE
prove for purpose of sale.). RES IND CON PB Ci
❑ L,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
wi licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Cade:The Contractor's License Law does not apply '
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)tic sed pursuant to SEWER-SANITARY-STORM EA:2001t/10.00 TRACT NO. PARCEL NO.
the Contractor's Lic se Law.
❑ lam exemp er dSec. ,BARC,for this WATER HEATER W/VENT 6.00
rea'so
Owner - Da - WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
hereby affirm that 1 have a certificate Of consent o a f- , - ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec_ 380,Lab.
Policy No ompanyy
Z ❑ Certified
Company
Copy is hereby furnished.he ' I - FIRE SPRINK ENERGY T34
Z 0 ❑ Certified copy is filed with the city inspection division. MISC.- REFER T00RD. 1
O Applicant v❑ N❑ v ❑, N❑
CC T PERMIT ISSUANCE 10.00
� - CEHTI FICCOMPF SA i ON IFROM WORKERS' FLOOD ZONE A.L.U.C.
IL need not-be oto INSURANCE it (he PLG.CONTR. LIC.N0: PLG. Y❑ N❑ Y ❑ N❑
Z Z hundred
action need not complete) if,he permit is for one - TOTA
hundred dollars[$100)or Iess3 •
U O 1 certify that in the performance of the work In,which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
Date P Applicant BUILDING
ALTER OR ADD TO MECH. 5.00
} y NOTICE TO APPLICANT: If,after making this Certificate of liz- -
F Z em vision you should become subject in Bre Workers'Compensation APPLIANCE 5.00 - PLAN CHECK
provisions of the Labor Code, you deemed
comply with FEE
such provisions or this pertinit shall be deemed revoked. AIR HANDLING UNIT(TO 10/100 C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY, AIR HANDLING UNIT(OVER I0=C.F.M.) 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. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM'
3097,Civ.CJ.
Lender's Name HEATI N G U N IT(OV ER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
V information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.Ror100,000B:T.U.) 6.00
r! hereby authorize representatives of this cityio enter upon lite BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL'
above-mentioned property for inspection purp(ses.
(We}agree o save, indemnify and k p harmless the City of MISC.- REFER TO ORD.
(Cupertino ag' st liabilities ju cents osis and expenses which '• pERM1T ISSUANCE 10.00 CONST.TAX
ma i any aycc a a' t sail ty in consequence of the
- 9o a MECH.CONT. LIC.NO. MECH. /
3^� TorAL - TOTAL
(gnat re I'A plicanf/ onlraclor i Uate
OFFICE COPY