3823 '1_1j1PPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
ToILDING
ADDAPPLICATION & PERMIT 3823
ADDRESS
+ B90 wp
0 �� � BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S 1 ��+�- PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
/ .l�� PtL _1` PHONE III
�CONTERACTORS q6 UTLETS-SWITCHES-RECEP 5.00/1.00 -
G--6O
. IrJ _r-L nuc.No. `/28 .LIGHTING FIXTURES 5.00/1.00
'POOR ESS TORS y APPLIANCES 4.00
�� p 27/�
D / VVI PHONE 7.il�J PANELS 5.00 Q DATE OF APPLICATION
ARCRRECr SIGNS B"00 �- PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIc.No. of!�-SIGNS TRANS. 3.00
ARCH.OR ENG, SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
20
ZIP TEMP.METER OR POLE INS. 15.00 is-
APPLICANT 5
APPLICANT'S $EE FEE SCH.ADDRESS 77,,; S�[
SERVICE CHANGE 10.00 0
o a o LICENSED CON"TRACTORS DECLARATION PAID
u 1 hereby affirm that 1 all, licensed order provisions of Chapter 9 ISSUANCE DATE
wQ n (commencing with Section 7000)of Division 3 of the Business and f r BLDG. ELE T. PLG. ISIFT.
F w z Professions Coda r141y lic,nse is in full Turco aytff ` -z D m License CI s. V Lic.Non.her 2 o w _ Date�rZ�$ Contractorw OWNIiR-BUILOF:RDLCLn RATION (� B(t)f10BUILDING PERMREF ER TO ORD INFORMATION
w ;LLNI herebyoffrm that I am exempt from the Contracmr's License MISC.- VAATION
rLLO J Law for the following reason(Sec.703 L5,Businessand Professions PERMIT ISSUANCE 6.00
io Code:Any city or county which requires a permit to construct.alter,
Q40 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO.C�-0 ELEC. _q�
D LL requires the applicant for such permit to file a signed statement that �' TOTAL v PERMIT TO
A whe is licensed pursuant to the provisions of the Contractors License -✓e-r ��
H z a Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
F o the basis for the alleg,d Oxen...Linn.Any vlolulinn of Section 7031.5 STORIES TYPE CONSTR.
ate - by any applicant for a permit subjects the applicauttoacoilpenalty ALTER-DRAIN&VENT-WATER (EA.) 4.00 '
of not than five hundred dollars(S500).):
❑ Inc.,as owner of the PmPerty,or my employees with wages as BACK F LOW PROTECT. DEVICE 2.00
their sole compensation,will do the work,and the structure is not DCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044. Rosiness and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code'.The Contractor's License Luw does not apply to an owner of
properly Who builds or improves themon.and who dot's such work FIXTURE$-PER TRAP 4-00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees.provided that such intprove-
memsarenomm,h his or offered for nemployee,, pre. ied that such
building GAS-EA.SYSTEM-1INC.4OUTLETS 4-00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving flat he did not build or am-- - RES IND CNG PB Omer
I prove for Purpose of sole.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑ ❑
p� ❑ I,as owner of the properly,am exclusively contracting with
n(j licensed contractors to cotrstruct 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 does not apply
0 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 comtrxetous)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/6.00 TRACT N0. PARCEL N0.
the Cnntmcun's License Law.
•9 ❑ lam exempt under Sec. .B.&P.C.lix this WATER HEATER W/VENT 4.00
reason
it, 0^'^er WATER SYSTEM 4.00 Acc,DATE ACC.FILE NO.
WORKERS'CONIPENSATION DECLARATION WATER TREATING EQUIP. 4.00
-7 1 h by Iltirm that I have a certificate of eun.,rt to sell-in,ume, ZONING ENG,SITE NO.
or a cer 'cat,of Workers'Compensation Insurance,or a certified
f� copy there Sec.3R00,Lab.C.1.�-'A'�.,`.'. c
I'oIICY , .is It Dy_ �-.1
Q ❑ Cetldco 'is hereby Tani bedJWKE
r FIRE SPRINK ENERGY L}4
Z Z ❑ Ce ificJ py is OIcJ Wi t t n divisio REFER TO ORD.
Ap..Meant _ _ MI'4C'- Y ❑ N❑ V ❑ N❑
F PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
CERTII4C.NTIS OF IiXEhl.'TION 1'RORS'LL CO htPliNSAT10N INSURANPLG.CONTE. uC.No. PLG.
d O (This section need not be completed if the peon it is for one TOTAL Y❑ N❑ Y ❑ N❑
D 2 hundred dollars(SIFF)or less.)
U O 1 certify that in 'Ile perfonnancc of the work for which Dlis per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL P mit is issued.I shall not employ any person in any manner so as to
Q U become subject to the Workers'Compeamtion laws of California.mBUILDING
a
Uc Applinu.t ALTER OR ADD TO MECH. 4.00
} N NOTICE TO MI': IC after making this Certificate of
F 2
Coalition.you ShOUl should bebecome subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the labor Code, you forthwith comply with FEE
U such provisions or this permitushut[
shall be dee deemed revokeA. AIR HANDLING UNIT(TO 10,0000 F.M.) 3.00
CONS'fROC'I'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10,OWC.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agenev for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this Permit is issued(SCC. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's NameHEATING UNIT(OV ER 100,000 B.T.U.)7.50 ELECTRIC Z/:?Lender's Address
I certify that l have read this application and state ilia(the above VENTILATION FAN (SINGLE) 3.00
information is correct, I agree to comply with all city and count) BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
oudinances and state laws (elating to building construction, and
hereby eu l nri a representatives aI' this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above mentioned property for inspection purposes. -
(We) agrtn to save, indemnuy and keep Imnnlcss the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may i y way uccrue u i st said City in consequc cc of the PER ISSUANCE 3.00
m• I this pc nuiL MECH.CONT. LIC.NO. MECH.
7/ p TOTAL TOTAL
Siglaturc ofA plicunt/ n Rector D: c
OFFICE COPY
C