11529 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT I IDENTIFICATION - PERMIT NUMBER
Sol
LOING APPLICATION•& PERMIT - 11529^ r ^^
ADDRESS BUILDING - ELECTRICAL-PLUMBING—MECHANICAL I I "�L y
5 Kv v
OWNER'S PLAN CHECK VALIDATION
"AMEOTV. ELECTRIC PERMIT FEE
CCj,kPNoruf - _
\ CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00 ✓'�'.
\ NAME
LIC.No. 7LIGHTING FIXTURES 10.00/1.00 -
rONTRACTORsPPLIANCES-RESIDENTIAL 4.00 -
ADDRESS
PRONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT 11Z�
DpI'D 200 AMP) 200
OEROI"EER vUJJU✓tL� - 3.00
C.NO. SIGNS TRANS.
ACHECK FEE P.C.NO.
ARCH.OR ENG, - - 5.00 PERMIT VALIDATION
'
ADDRESS „�— SPECIAL CIRCUIT ,
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
110%I1 SERVICE CHANGE 20.00 /y3 jrn
C o LICFNSI;D CONTRACTORS DECLARATION
a u v I hereby affirm that I am licensed under provisions of Chapter 9 9 -7 ISSUANCE DATE
Is Q a (Cc mmencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
0 tj i Licenssion�Cad `my license is in full fort-' fe- ❑ prI N_z o m - Cicero—Class_ CR Number II// hAI C�-
9 m .w Dale Contractor h" -
a y � )s��` 6 _ BUILDING PERMIT
-BUILDER DECLARATION
INFORMATIONOWNER
3 1 hereby affirm that 1 am exempt from the Contractor's License MISC.-w VALUATION
$/FT.
a.u.
o IA Law for the following reason.(Sec,7031.5,Business and Professions PERMIT ISSUANCE 10.00
y Code:Any city or county which nsluiresa permit to cDnstmCL ateq ELEC.CONTR. LIC.NO. - r^--s
Fo improve,demolish,or repair any structure,prior to its issuance,also _ ELEC. 3O eyla
O Q mquirn the applicant for SIICh pl'llllll to file J Signed statement tM1at 'T• r TOTAL PERMIT TO
' w m" he is licensed pursuant to the provisions of the Contractor's Licenx '— - , a
Hii Law(Chapter 9(commencing with Section 7000)of Division 3 mill E�•L�-7� ��-(.)� ��
a Business and Professions Code)or that he is exempt theand QTY. PLUMBING PERMIT FEE
r c the basis for the alleged exemption.Any violation of$ection 7031.5 STORIES TV E CONSTR.
y '; W by any applicant]or a permit subjects the applicant loll civil penalty gLTER-DRAIN&VENT-WATER (EA.) 5.00
01'not more than five hundred dollars(5500).)'.
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure n not
intended or Offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of p
property who builds or improves thereon.and who does such work FIXTURES-PER TRAP - 5.00 SO.FT FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-i INCA OUTLETS 6.00
ments are not intended or offered for sale.11,however,the building
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
.
builder will have the burden of proving that he did not build or im- RES IND , DON PB Goner
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License Law dues not apply
to an owner o1property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contmctoRs)licanwd Pursuom to SEWER-SANITAR V-STORMEA.200ft/10.00 TRACT NO. PARCEL rvO.
the Contractor's License Law. .Cl I am exempt under Sec ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date, WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WAT ER TREATING EQUIP. 5.00 '
I hereby al Ore that I have a certificate of amssnt to self-insum. ZONING ENG.SITE NO.
or.certificate of Workers'Compensation Insurance,or a ceril'ied
copy Ihereof(Sec.380,LahC.I -
Policy N CompanY_�/.,y.�7{��/
Q ❑ eltihcd copy is hereby burnished. FIRESPRINK ENERGY T-24
Z Z l�ffi le wIT th el coon division. MISC.- J /�' ER TO ORD. y ❑ N❑ v ❑ N❑
Applicant s n
h - _ PERMIT ISSUA E 10.00 FLOOD ZONE
.A.L.U.C.
— CF.RTII°ICA'I'r OF E1F11TION FR M WORKERS'
GJ > CO4EMA'1'ION INSURANCE - P oN PLG. Y❑ N❑ v ❑ N❑
CL O (This section need not be completed if the permit is for one TOTAL
Z) z' hundred dohms(S100)or less.)
U 0 1 certify that in the performance of the work for which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shun not employ any person in any manner so as to
O W Ncolne subject to the Workers'Compensation Laws of California. _ BUILDING
Date Applicant ALTER OR ADD TO MECH. 5.00
} N NOTICE TO APPLICANT: it.after making this Cctlificate o1'Ex__
♦- ? emption,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
Provisions of the Labor Code, you most forthwith comply with FEE
L) such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION'LIiNDING AGENCYAIR HANDLING UNIT(OVER I0,000C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5,00
the performance o1'the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00
3097,Civ.CJ. MICROFILM
Lender's Name HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC 30 ✓
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county BOILER-COMP I3 H.P.Or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorise representatives of this city Io enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL rJ
above mentioned property for inspection p op.,c
(We) more to save, indemnify,and keep haonless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which Q ori CONST.TAX /
may in any way accrue,against said City in consequence of the PERMIT ISSUANCE 10.00
granting of this per�"�� � 11 � MECH.CONT.. 2'CC.NO. MECH. /
mAd 1 iLlA '1�-8W Z K,� (3 / �Z TOTAL -7Jti TOTAL 7
Sign4luroof Apphcrrt/ tractor Date -
OFFICE COPY - r