1986 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL. POINT PEN ONLY W
BUILDING PROJECT IDENTIFICATION PERM( Num R
APPLICATION & PERMIT 2 75--
ADDRESS 5c, - 186 L+
2 Si M y f_4. �7- �; V F BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 0 U
0NER'S / .[J}S p� Z r. _ �,:w [r *, �,� PLAN CHECK VALIDATION
NAME � J_ OTY. ELECTRIC._PERM17 FEE .
Y D/' L•i /.? /pS10RE �. rJC7 s I.
.CONTRACTORS -
Name i�x7• UTLETS-SWITCHES-RECEP 5.00/1.00
C w;N z- <'14 11 tAr LIC.NO. S `i/ LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S
ADDRESSSly ` �b�c.t PPLIANCES-RESIDENTIAL 4.00
G+� ,CORE ONE !6G-SF'�- PANELS 5.00 DATE OF APPLICATION
onnCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
Llc,No, SIGNS TRANS. 3.00
ADDRRESS ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
zlv EMP. ETER OR POLE INS. 15.017
ASS MOTO SEE FEE SCH.
ADDRESS
SERV CE C A E 10.00 / p
Woo LICENSED CONTRACTORS DECLARATION
u u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
,I-,s <y (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT; PLG. MECH.
r H z Professions Co ,and my lice u is in full force and effect. ❑ ❑
Z. License C 'Y�Lic.Number ;�`r7 '�
° h H Datc Contractor rd waw_r�InA C' r�
a y s F VI N' .'SBU IL'DIN0 PERMIT q
a s a
OWNER-BUILDER DECLARATI N 'r-v: ••g +-
u ,�a.a:,� ;.;INFORMATIONr
X r.w I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD "'
H VALUATION S/FT.,
tuN J Law for the following reason.ch(Sec.
req U31.5,ermBusiness t tocand Professions PERMIT ISSUANCE 6.00
w i
Code:Any city orcounty whichstructurepermittoconsuacLalter. 9aj.,a
X a < Q improve,demolish,or repair any seroclure,prior m its issuance.also ELEC.CONTR. LIC.NO. ELEC.
° I, requires the applicant for such permit to file a signed statement that TOTAL PERMIT T
F
$
in be is licensed Pursuant to the provisions of the Contractor's License _ n _
> Law(Che ter 9(commencin with Section 7000)of Division 3 of the u ,";� Y, i II s 3 oJ•F-a-�
i c Business and Professions Code)or that he is exempt therefrom and OTY. - q4 •''9 PLUMBING PERMIT I}.4�d4v41 t FEE�Nf -
a I-$ the basis for the alleged exemption.Any violation of Section 7031 5 ° • 41-.3bt' 1 '.%I:O F3.'4i'i,:+' d . STORIES TYPE CONSTR.
by any applicant to,a permit subjects the applicant toacivil penalty ALTER-DRAIN IEA.14.00 `
or not more than five hundred dollen(5500).1:
❑ 1,as owner of the property.or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered 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 dues such work FIXTURES-PER TRAP 4.00 56 FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
C w menta are not intended or offered formic.If,however.the building GAS-EA.SVSTEM•11NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM•OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im•
prove for purpose of sale.). RES IND . CON PB Other
C) Las owner of the propeny,am exclusively contracting with INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑ ❑
licensed contractors to construct 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
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 contractors)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCELNO.
❑ 1 am exempt under Sec. ,B.&P.C.for this
reason WATER HEATER W/VENT 4.00
Date Owner WATER SYSTEM 4,00 .. ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 4.00
I hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certifscam of Workers'Compensation Insurance,or a certified
copy there ISec.3B00•,}.ab.C.). r
Policy No °�/ Ca Jany
Q ❑ Certified copy is herby famished, FIRE SPRINK ENERGY T'24
Z ❑ Certifmd ca y is filed with e c ly inspection division.
f �wi .ilk r.. •Y MISC- REFER TO ORD.
APDlicanl�,. Y❑ N❑ Y❑ N❑
w /� PERMIT ISSUANCE 6.00
LU CERTIFfGMMPENSAEM B MWORKERS' PLOOD ZONE A.LU.C.
W � COMPENSATION INS ANCE PLG.CONTR. sec.NO. PLG.
CL 0 (This section need not be completed if the TOTAL Y❑ N❑ Y❑ N
p permit is car one
C.7 O hal eertif oltlars(S hat in °er(ormanee of the work for which this er. 9 w :n-0v kc H^•a' x . Iv y++ml[• 5 / n'r"h qs 'P 9:.�h71 �`w 'w"11. >e- -
y p p QTY. I^ MECHANICAL PERMIT P-T r FEE x!-ap-:-,EPEE 8UMNIM-
LL I- mit is issued,I shall no[employ any person in any manner so as to v,h. <-wr,c „ A I I+,_MN y«;,_ I t ,s/f-'+ �
OW become subject to the Workers Compensation Laws of California. ' BUILDING
Date APPlicanl ALTER OR ADD TO MECH. 4.00
>_ H NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z emption,you should became subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions or the Labor Cade, you must forthwith comply with FEE
V such provisions or this permit shall be deemed revoked, AIR HANDLING UNIT(TO 1OXIC.F.M.) 3.00 �)
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=111F.M.) 5.00 SEISMIC FEE s -
I hereby afftma 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. MICROFILM
7097,Civ.C.l. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender s Name h 1/�+
Lenders Addre7 HEATING UNIT(OVER 100,0008.T.U.)7.50 ELECTRIC
/ 1 certify that I 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 'PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned propeny 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 PERMIT ISSUANCE 3.00 CONST.TAX
may in any way�cerye agains[n consequence of the
granlln80 wpe MECH.CONT. LIQ NO. MECH.
/ iAn TOTAL
4, --"
--s SOTALr: : f
Signature of Applicant/Contmcmr Uane R,iy.,,(,,;•,-'F'r,%1.
OFFICE COPY