18808 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDING PR JECTQ. IDENTIFICA 10�� N Jf' PERMIT NUMBER
rsx� APPLICATION & PERMIT ''-� � 0008
anlh O 0
An. �/� l 1/� CO /--ffDe/ �A GILDING-ELECTRICAL-PLUMBING -MECHANICAL a,On
OWNER'S / [ _ ' PLAN CHECK VALIDATION
"A411-,r
S /P/.�}-���/1�'rfr O7V. ELECTRIC PERMIT r ���{{�(�/�
(�/ ✓ / f (/' �f PHONE RQQQ
CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00
NAMf , (✓4 G LIC Np J ✓/ V✓f LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
ADDRESS A , p, 9ff/ PPLIANCES-RESIDENTIAL 4.00
AL �`�j
�f l PHONE �( 173 PANELS 10,00 DATE OF APPLICATION "
ARCHITECT PANELS (OVER 200 AMP) 26,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC NO, SIGNS TRANS. 3.00
AR. E.G. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
55
file TEMP.METER OR POLE INS. 20.00 .)0 /1/T`UR�1KGi
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS Alp� /telA.
A 4. iLr//,j SERVICECHANGE 20.00
0 0 o LICENSED CONTRACTORS DECLARATION
a u U I hereby aThr..,that I am licensed under pruvio.ns of Claplcr 9 OCT 2 `r I58 �/"`3 ISSUANCE DATE
m Q w (conunemdng with Sec ion 00)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H H z I'rol'essions Cod cense is in full fanc",Plic0,4 I�
Z, z m o License Class_ Lic.Number V ((// [ upe Inc
F Dutc��- � _ Coo tractor r r V
ay � � BUILDING PERMIT
Ir w -a OWNIi R-BUILDER DECLARATION INFORMATION
woar MISC.- REFER TO ORD
3 LL I hereby aflinn that I am exempt from the Contractor's License
u_o to Law for the following reason.(See.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 y VALUATION S/FT.
r - Code:Any city or county which requires,permit m construct,alter. W '
2 Q 2improve,demolish,or repair any SlorC urc,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. l-(J
- o a, requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
E:
$ he is licensed pursuant to lire provisions of the Contractor's License n
�zQ
Law(Chapter 9(commencing with Section 7000)of Uivision,3 ofthe
Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
H Oo the basis for the alleged exemption.Any violation ol'Section 7031,5 STORIES TYPE CONSTR.
ow. ;E by any applicant tot a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
nl'not more than five hundred dollars($500).):
❑ I,as owner ol'the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 DCG GROUP RES.UNITS
their sole conhpemsatiom,will do the work,and the structure is nm
intended or offered for sale(Sea 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code Tire Contractor's License Law does not apply man owner Of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SC.IT,FLOOR AREA TOTAL ACREAGE
himself re utfI,tb his own flcrcd forsale,
pnwid to that such inUrrove-
nantsarenotlmcndcdorOfl'c,loyce sa rovideo that such
building GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00
or improvement is sold within one year of conhpletion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ Iof ❑ ❑
❑ I,as owner of the property',am exclusively contracting with ,L11
licensed contractors to construct the project(Sac.7044,lousiness LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code The Contractor's License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contraclorls)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contmetco s License Law.
❑ I am exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK IiRS'COAf I'IiNSA'fION DECLARATION I E TA? T}(•x1G U 5:00
I herethy affirm that I have a certificate of consent to self-insure. .. _ `i x, I' II- h hl ZONING ENG.SITE NO,
or aertificat((e$$of W��o�rkQers'Com))��pp�ee�rsatiy t Insuranccee,,mor -O -d // _
Copy
ab .
Policy N�o��E7 o hpuny
O ❑ Fluted copy is hereby limnkhed. 1 FIRE SPRINK ENERGY T40
z Z WCerlified p Is f � w10h he cit ins division.
O Applicant e 1-re _ MI�F�IE OR . Y❑ N❑ Y ❑ N
CERT FICA 117 OF li AIiMPTION FROM WO uiRS' ERMITISSUANCE- ---1111 0 FLOOD ZONE A.L.U.C.
>_ COMPIiNSA'I'ION INSURANCE PLG.CONTR. LIC.NM PLG.
1 0 ('Phis section need not be conhplcted it' the permit is for one TOTAL v❑ N❑ Y ❑ IN
Z hundred dollars IS 100)or less.)
U O 1 certify tat in the performance Of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit uA,1 hull not employ any pe n any man u,
w becolJ,c�nyb m Workers C fn n/)
Dal Applieanl_L ALTER OR ADD TO MECH. 5.00 BUILDING .W
} w NU I T( AI I'LICANI': II, a ma hIs'.erti teat of :N-
F Z cmpllrn,you Should become subject tr the Workers'Cnmpc firm APPLIANCE 5.00 PLAN CHECK I r 5S
provisions of the Labor Code, you must forthwith comp with FEE
U such provisions or this permit slall be deemed revoked AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 100000-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 h,r which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.0.).
Lender's Name H EATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that l have read this applicufionand slate that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and stale laws relating to building construction, and
hereby authority representatives of this city m enter upon lire BOILER-COMP IOvef I00,000BTUISEE FEESCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree to save, indemnity and keep harmless the City of misc.- REFER TO ORD.
Cupertino a•uinst liabilities,judgments, costs and expenses which CONST.TAX
may a way accrue against sat :'yin consequence of which
PERMIT ISSUANCE 10.00
rI tin trite LMECH.CONT. LIC.NO. MECH.
�3 TOTAL rj7. 05j
Ig amre of Applicant/Contractor Date
OFFICE COPY