6620 APPLICANT TO FILL. IN INFORMATION WITHIN RED LINES = USE BALL POINT PEN ONLY,
BUILDING PROJECTI DENTE FICATION - PERMIT NUMBER_
uuaOlrvG APPLICATION 81 PERMIT - �n1
/ `I`�f7I�LlY ..p t V�V.Y O
�f Aoonsss
(n1 //�BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
VA FwsN'
OWNER'S,.r .. .
PLAN CHECK VALIDATION
QTY. ELECTRIC PERMIT FEE
PHONE'. r
Name AcrDR's UTLETS-SWITCHES-RECEP' 5.00/1.00
W�Z� ��A$�I.CO�CC7.�O•,c.
No.,'Il 9" '$ LIGHTING FIXTURES' 5.00/1.00
CONTRACTORS
DR " APPLIANCES-RESIDENTIAL 4.00
D'A'sS63R " fr"pHorvEt , 1Q• i PANELS 5.00 . DATE OF APPLICATION
ARCnITECT f' PLANCHECK;FEF P.C.NO. ,
OR ..STeFB��'./�I(I�A�Ary�\�GCIr�1 SIGNS ' - 6.00 .
ENGINEER';S PATTY�Trr'
'uc.No. SIGNS TRANS, r - 3.00 I+ .
ARCH.OR ENG.," - PERMIT VALIDATION
AR R ss ^" SPECIALCIRCUIT-- '5.00.
V I 'Zip EMP.METER OR POLE INS. 15.00
ADDRESS, MOTORS "' : SEE.FEE SCH:
X" 32. RH Q .,$` � q SERVICE CHANGE 10.00
I�a o ,LICENSED CONTRACTORS DECLARATION - -
r¢ is U I hereby affirm tlml',f am licensed under provisions of Chapter') ` ISSUA(((NCE 0/ATE
Z m (commencing with Section 7000)of Division 3 of the Business and
w¢w BLDG. ELECT. PLG. MECH.
r w z Professions Code,and license is in full force al d f cl. - ❑
z o•+, License Clans Lic.Number •❑
F D .Date L. ey Contractors I El
P: Y P - ��,,pp NlC _ BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDER OECLAf�ATION
o a u - INFORMATION
X g LL N I hereby affirm that 1'am exempt from the Contractor's License MISC.- REFER TO ORD
FnC, Law'for the fN]owing reason.,(Sec.7031.5,Business and Professions 'PERMIT ISSUANCE 600 VALUATION $/FT.
Code:Any city or county which requires permit to construct,alter, `'
„Q Eli
¢¢Q improve,demolish,or repair any slmclurc,.prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
C,u requires the applicant for such permit to file a signed statement that _ TOTAL pEBR�7 O
n w m he is licensed pursuant m the provisions of the Contractors License -
>
Law(Chapter 9(commencing with Section 7000)of Division 3 of the LW
QQ '}
Business and Professions Code)or that he is exempt therefrom and GTY. PLUMBING PERMIT LWEo' �•�d/`AES L '
¢ f m the basis for the alleged exemption.Any violation of Section 7031.5 + STORIES + TV PE CONSTR. C
by any applicant for a permit subjects the applicant Iota civil penalty
ALTER-DRAIN&VENT-WATER (EA.) 4,00
of not more than five hundred dollars($5007.): - BPBIt IRO -
❑ I;as owner of the property,ormy employees with wages as BACK FLOW PROTECT.DEVICE Via" 2.00 OCC.GROUP RES.UNITS
their sole compenmlion,will do the work,and the structure is not
intended'orloffcred for sale (Sec. 7044, Business'and Professions DRAINS-FLOOR,-ROOF,AREA,COND.-4.00 ,
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 4.00 SO,FT.FLOOR AREA TOTAL ACREAGE-
himself re of rote his own employees Provided that such improve-- . .
1 mems o not through
or offered employees,
provided
ed that such
building. GAS-EA.SVSTEM-11NC.40UTLETS 4.00 s
or improvement is sold within one year of completion,the owner; GAS-EX.'S V STEM-OVER 4 IEA.) 1,00 '.BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND . CON E Omer .
prove for purpose of sue.). 1 INDUSTRIAL WASTE INTER. 20.00
❑- Las owner of the properly„am exclusively contracting with ❑' ❑ ❑ .❑ -,.' ❑
licensed contractors ..construct the project(Sec.•7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL'NO.'
and.Professions Cod.The Contracto'r's License Law docs 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 eonlractor(s)licensed pursuant to 1
the Contractor's License Law. - SEWER-SANITARY-STORM•EA.200ft/8.00 .TRACT NO. PARC EL'NO.
❑ [am exempt'under Sec. ,B.&P.C.for this I ^
Reason WATER HEATER W/VENT 4,00
Owner' Date WATER SYSTEM 4-00 'ACC:DATE ACC.FILE NO.,
+`•-WORKERSWOMPENSATION DECLARATION WATER TREATING EQUIP. 4.00 .. -
1 hereby affirm that I have a certificate of consent to selfinsure, " ZONING
a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.1" Jf�,
Policy No. Company IT
- ❑ Certified copy is hereby furnished. It WC'14IN33 , " FIRE SPRINK ENERGY T-24.
❑ Certified Iry is file) itp the city in peeI p divumn.
Z ZOn .Applicant 61ZA� Ilplllel Cnrtceutt[tal'ay>. vd . MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
cc vi PERMIT ISSUANCE .• 6.00 FLOOOZONE. A.L.u.c.
(r CERTIFICATF OI°EXEMPTION FROM WORKERS'
UJ COMPENSATION INSURANCE PLG"CONTR. LIC.NO: PLG.
d O (This section need not he completed if the permit is for one •TOTAL Y❑ NF] Y❑ N❑
D Z hundred dollam($100)or Tess.)
U O d certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
UL 1-' mit is issued,1 shall not employ any person in any manner so as to
O W r become subject to the Workers'Compensation Laws of California.
UJ Date Applicant , ALTER OR ADD TO MECH. 4.00 ^ BUILDING e• `
} N NOTICE. TO APPLICANT: If,after making this Certificate of F.x- -
F Z emplion,you should become subject,to the Workers'Compensation APPLIANCE , 4,00 PLAN CHECK Q� L
provlsrons of the'Labor Code, you'must forthwith comply with FEE /
U such provisions or this permit shall be deemed revoked, AIR HANDLING UNIT(TO 10p00C.F.M1 3.00 -
• ' CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10XDO.F.M.) 5.00 SEISMIC FEE . ,r
I hereby af(irm'thal there is a coristrucrion lending agency for LEXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ.CJ. - -
Lender'sName f HEATI NG.UN IT(OV ER./00,000 B.T.U.)7.50
der.'e
LenAddress' - ELECTRIC
I certify that l have read this application and stale that the above VENTILATION'FAN (SINGLE) 3.00
information is correct. I agree'lo comply with all city and county - PLUMBING
romances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.)'4.00
hereby author7c representatives of this city to enter .,on theBOILER-COMP. (Over 100;000 BTU)SEE FEE SCH. MECHANICAL '
above-mentioned 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
N,
in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00 _ ,
Rr'W'nI t permit. MECH.CONT.'' - o LIO.NO. • MECH. x '�
wOy TOTAL
6188 TOTAL a 3.
' Signal re of Applicant/Contra.... - Dee -
�pfL„
6A;T1. lel%% ZIca'.P(C-• - "n OFFICE COPY,