17831 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON PERMIT NUMBER
Rl1ILDING - APPLICATION &•PERMIT
SS 17'
ADDRE
2Q64 �DT �., _ UILDING—ELECTRICAL—PLUMBING—MECHANICAL �;- 1 1 831
OWNERS ' �yNL.�g�yvyW PLAN CHECK VALIDATION
NAM LA
�� I I �f QTY ELECTRIC PERMIT FEE
• vusOxE 7 '-t
NAMERAc oRs.�„� n,�g� y� UTLETS-SWITCHES=RECEP 10.00/1.00
�C/7 //f- sec.
NO LIGHTING FIXTURES -10.00/1.00
CONTRACTDR PPLIANCES-RESIDENTIAL '4.00 _
ADDRESS /
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITICI PLAN CHECK FEE - P.C.NO
on PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. - PERMIT VALIDATION'
ADDRESS SPECIAL CIRCUIT - 5.00 1 /
zIv EMP. METER OR POLE INS. 20.00
ADDRESS S
AMOTORS SEE FEE SCH. (((
ORE
SERVICECHANGE FAJQ 20.00 �-I �T L1:V(6 Ir
woo LICENSED CONTRACTORS DECLARATION 1
< v u 1 herchy'affirm that I am licensed under provisions of Chapter 9 MAY i /� 19,`,a IJ ISSUANCE DATE
m G H (cm
omencing wsen
illt Section 70001 of Division 3 of the Busin. d BLDG. ELECT. PLG. MECH.
F w z Professions Code,and my license is in full force and effect- p��tl V -
Z 0,A— Licen.Class Uc.Number
o H e, Datc Contractor
City (;IIOP,(fIRO - /' E'
-
a Y BUILDING PERMIT
¢ ¢ < OWNER-BUILDER DECLARATION
¢ w u INFORMATION
wLL vH, I hereby affirm that 1 am exempt from the Contractor's License MISC.— REFER TO ORD VALUATION
FLL04 Iaw for t he following reuyns.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 5/FT.
Code:Any city or County which requiresa permit to construct,alter.
a2 ¢Q improve,demolish,or repair any%suctem,prior 10 its isamii also CLEC CONTR. LIC,NO. ELEC.
0 ¢ requires the applicant for such permit to file a signed statement that TOTAL Cjj
ia PERMIT TO
w $ he is licensed pursuant to the provisions of the Contractor's License ^ v
F z a Busi(Chapterand
Pmromrnancing Code,or Section is C0Cof tDivisionheft.. the ��7 V 1 D ■ 1
Business fur
he 11,od s Codd or that he is tion pt therefrom and DTV. Fu NG +— N S
¢ =$ the any
Ito alota ermnpubj Any applicant
tol toacliun en LS 1 Y STORIES TYPE CONSTR.
d3 hyany applicant lore permit subjects lheepplicant toacivil penalty ALTER-DR I ( A.
.four more than five hundred dollars(S500)d:
D 1,as owner of the property,or my employees wit wages as BACK FLO RO E I OCC.GROUP RES,UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (See. 7044, Business and Professions DRAINS-FLOCDAIWF,AREA,
Code:The Contmemr's License Law docs not apply to an owner of f”
property who builds or improves thereon,wsl who does such work FIXTURES,PER TRAP SEE FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments
mprove- - -
mentsarenotintendedorofferedforsale.IL however,the building GAS-EA:SYSTEM-11NC.40UTLETS 6.00 j6 C*AF-AM
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 �JU -1C.1.-�
builder will have the burden of proving that he did not build Or ice- BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30,00 REs IND CON PB Other
❑ 1,as owner of the properly,am exclusively contracting with ❑ ❑. ❑ ❑
licensed cuntraclur� to construct the project(Sec. 7044,lfuxiness LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contracmr's License Iaw 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 contraetols)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00
the Contractor's L leense Law. TRACT NO. PARCEL NO.
❑ l an,exempt under Sec. .BAP.C.for tis WATER HEATER W/VENT 6.00
Raven
Owner Date WATER SYSTEM - '5.00 ACC.DATE ACC.FILE—NO.
WORK ERS'COMPENSATION DEC1 RATION WATER TREATING EQUIP. 5.00
I herchy uffum Ilial I have a certificate of consent to self-insure, - ,_ ZONING
or a certificate of Workers'Compenschon Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.380) 1.C.1.
Policy N'o. ryrypany
O ❑ Cerllliedcop i (cre,yfurnklod. FIRESPRINK ENERGY T-24
O enifmJo filed sijll t city inspe i n division. MISC.- - REFER TO ORD.
Q Ap ictint Y❑ N❑ Y ❑ N❑
CC Ln C INC\TIi OF I: EM 'IO 'ROA1 WURk ERS' PERMIT ISSUANCE 10.00 !� FLOOD ZONE A.L.0 C.
W 1 COAfPENSATION INSURANCE PLG.COINER, LIC.NO. - PLG. I W� YE] N❑ Y ❑ N❑
O Cl his melion need not be completed if the permit is for one TOTAL
Z- hundred dollars IS 100)or Tess-)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I staff not employ any perNm in any manner so as to
O become subject 10 the Workcrs'Comti
pensaon Laws of California.
0 a Dale Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE'1'0 APPLICANT: 1f,after making this Certificate of En- ✓T
Z cmpti in,you should becnotu s.bj"l to the Workco'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,OODC.F.M) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING IINIT(OVER 10=C-EM.) 6.00 SEISMIC FEE
1 hereby affirm that then is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's No HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC 13— ._
Ieertil'y that I have read this applicatimi and state that the above VENTILATION FAN (SINGLE) 4.00 �Da
nfbrtna1mit Is correct. 1 agree to comply with all city and county PLUMBING
ordinances and slate laws relatingn
to building construction, and BOILER-CONPOH.P.or 100,000B.T.U.) 6.00 1 —
hereby authof7c rumesontatives of this city to enter upon the
aton mentioned property forim penion purposes. BOILER-COMP IOser 100,000 BTU)BEE FEE SCH- MECHANICAL 5
(We) agree vc, indemnify and keep harmless to City of MISC.- REFER TO ORD.
Cupertino a liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 /� CONST.TAX �1
fay in a ay ace c xgu' st mid City in con. ence f the I L — 1 L-
Nin is penMECH.CONT. LIC.NO. MECH.
TOTAL51 fog TOTAL p
' tet re u A pli and Contractor to '
OFFICE COPY