5507 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LOI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 5507
,y AD ywt �•f/ �j �Nj(f,��/j� UILDING-ELECTRICAL-PLUMBING-MECHANICAL
wry ER's ` _ (,s t '�, �' PLAN CHECK VALIDATION
NAME /q Gr'{1{� . -jr�'.. JE,LTECTprIC P.ER}MIT �(�� E,
A) PHONE iSA.t a 4 4r,^.'TS, i4-;f OY��%h'__MIMI .IrMit ,re
• °\ CONTRACTORS
NAME UTLETS-SWITCHES•RECEP 5.00I1.00
CLQ Ic.No ILIGHTING FIXTURES 5.00/1.00
r.ONTRAcrofla PPLIANCES-RESIDENTIAL 4.00
PHONE IrPANELS 5.00 DATE OF APPLICATION
ARCHITECT 6.00 PLAN CHECK FEE P.C.NO.
OR SIGNS
ENGINEER 3.00
L.C.No. SIGNS TRANS.
ARCH.OR ENG. 6.00 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT
ZIP EMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00 &/4.1
W o o LICENSED CONTRACTORS DECLARATION Pto
AID
FZ u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
u' Icommrncing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
�w i Professions C �•an cerise is in full fo 1$B14 ❑ ❑
Z o w Licen la sec.Num 11S7f'I
0 m w Date Comndor
- LI «B'IL'DING'P,ERMIT
0 w U OWNER-BUILDER DECLARATION j j MATION FTI
a'x;u N I herebyaffirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
P VALUATION S/FT.
F LL o j Law for the following reason.(Sec.703 1.5,Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,alter,re au
<2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
o u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
A wm he is licensed pursuant to the provisions of the Contractor's License
r Law(Chapter 9(commencingwith Section 7000)ofDivision 3 of the wJUi£l " ." ".1:1:'Y$i...i�':ti 'aS:�".'L',' per* t'9• "^ zee���dr AZT.
a Business and Professions Code)or that he is exempt therefrom and DT�!'."' BI:UMBING.PERMITq*� /.
$ the basis for the alleged exemption.Any violation of Section 7031.5 ?V4.0'. :.r".-r3-!s}`1, 'wlt`'-'12.'E�' 7t6'. t�tl?yi STORIES ^TYPE CONSTR.
a;- by any applicant for a permit subjects the applicant 10 civil penalty ALTER-DRAIN& VENT-WATER IEA.) 4.00
of not mom than five hundred dollars the appl: �
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROu AES.uNlTs
their sole compensation,will do the work,and the structure u not
intended or offered for sale(Sec. 7D44, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 a•e P (,.(DLT
Code:The Contractor's License Law docs not apply to an owner of
properly who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 4,00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his awn employees,provided that such improve- GAS-EA.SYSTEM-1 INCA OUTLETS 4.00
ments are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner.
builder will have the burden ofproving that he did not build or im- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
P g RES IND CON PB Other
prove for purpose of the.l. INDUSTRIAL WASTE INTER. 20.00
O 1.d as owner of the property,he exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to the project La 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
to anowner of properly who builds improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contracted sl licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-.BAP.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that 1 have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Wyorrmrs'Compensa�ti-onnIIjns-urance.or a certified
pop WL
//7/ �' l/
Pop �Mn�pony
Q milld opy is hereby furnished. FIRE SPR INK ENERGY T 24
Z Z ❑ Certifi,zll PY is Bled with U "ty impsAmn division. MISC- REFER TO ORD. Y N❑ Y ❑ N❑
L •pplica
LU rn PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
CC - RTIFICATE OF :X- IPTI N FROM WORKERS'
W >_ COMPE 5 ION INSURANCE PLG.CONTR. LIC.NO. PLG.
all TOTAL Y❑ N❑ Y❑ N❑
= Z (This section need n e completed if the permit is for one
hundred dllars(SI00)� less.) P ! + .,,s.e ' eyy"7y.!'r.t�',tfan.` z"'RV +�v `` +e kFEE'.Sl1MM
6) O I certifythat in the erformance of the work for which 1h IS er. QN• +- �)yMECHANICAL PERMITI TtFEEe &a ..A
LL I- mit is issued.I shall not employ any person in any manner so as to )adr R .t^"a"r ev`.z�+3A`s','"P+,'�fi`.T,af.-z#adz ,L- ,_h` wa, y� Ctn, �/
OW become subject to the Workers'Compensation Laws of California. BUILDING T�Zs
d Date Applicant ALTER OR ADD TO MECH. 4.00
} rn NOTICE TO APPLICANT: If,after making this Certificate of Ex.
r Z caption,you should become subject to the Workeri Compensation APPLIANCE 4.00 PLAN CHECK
Provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10AWC.F.NL) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=11F.M) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST 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.C.).
Lender's Name HEATI NG UN IT(OV ER 100,000 B.T.U.)7.60 ELECTRIC
Lender's Address
I certify that)have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county BOILER 13 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construction, and
•,•. s.• hereby authorize representatives of this city to enter upon the BOILER-COMP love,100.000BTUI SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against Babilities,judgments, costs and expenses whichCONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
gran' o his permit . ECH.CONT. LIC.NO. MECH. T4+µ;�Sv:f•. k5
TOTAL .-• •IOTA / �+ ry
Ignatnre of App c /Contractor Date
OFFICE COPY