14127 (3) APPL ICA N i TO FILL IIV INI-O'tPrLA T ION WITHIN RI=D LINES - USF I`,ALL II,)INT PEN ONLY
BUILD( G PROJECT IDENTIFICATION PERMIT NUMUER
�AAUDAUES�ILn O a APPLICATION & PERMIT
- BUILDING - ELECTRICAL-PLUMBING-MECHANICAL _S2.LJ17�
D NER't I PLAN CHECK VALIDATION
NAME ,l' �'-
DTV. - ELECTRIC PERMIT FEE.PRONE .42.y.rPj
Ca iAcrO
NAME '-' "' '• ! OUTLETS-SWITCHES-RECEP 10.00/1.00 a
uc No, LIGHTING FIXTURES 10.00/1.00
I;U"IRRCTORS .22
ADDRESS l /�5•/ PPLIANCES-RESIDENTIAL 4.00
S / / I/ PNONE) L rJ4.4 - PANELS 10.0(j Q DATE OF APPLICATION
aRCNITEC. ,Vdiu_ �. c O ; PANELS (OVER 200 AMP) 20.00 1 PLAN CHECK FEE P.C.NO.
OR ll
ENGINEER
IC.NDICL- _ SIGNS TRANS. 3.00 I
ARCH OR �
aPERMIT VALIDATION
0 Ess v SPECIAL CIRCUIT 5.00 '
APPLICANN T'S/ C zIP EMP.METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCH. `Q
SERVICE CHANGE 20.00 Imo. �•�
ID
o o LICENSED CONTRACTORS DITLARA'IIUN 3//y4(lit
¢ i w I launch,affirm Ihul I all HLusad under provtsimu of Chapler 9
w ¢ a. IComnuncing with Section 7000)0lDivision 3.1 the Blaine,,unit ISSUANCE RATE
v. 0_ Professions Code lid ty liernsc is in fu 11 l'mcva I I t BLDG. ELECT. PLG. MECH,
z o= Liccntt Class_.�Lic.Number��f1j:(- �r
,On r w Dule Contract.,
Q y 1 J
w u OWNER-BUILDER DECLARATION BUILDING PERMIT.
w ; ` ,Hn I hereby affirm that I unl exempt (rum the Contract.,',License MISC.- REFER TO ORD INFORMATION
Huo ¢ Law for the followingreosmn(Sec.7031.5,business Slid plot i sham
PERMIT Cade:Any city Or County which requiresu permit tuconstrllet,alter, ISSUANCE 10.00 Q VALUATION S/FT.
¢ ¢ ¢ 0 improve,demolish,or repuirry u >Irucf are,prior to its issuance,also ELEC.CONTH. LIC.N0.
o LL retinues'he applicant Iia such permit to tilt a signed slulemenl(bat ELEC. -r f /
n w he is licensed pursuant W the muviaical of 111,Conln¢lura Linmx, TOTAL f/ /
1- zi
Law(Chapter 9(cuouneaciag will'Seel tell 7000)of Division 3 of tilePLIImIT TO S�'adWL
E i o Business and proe'soms Code)or that he is Cxempl Ihcmlimn and DTV. . PLUMBING PERMIT FEE
¢ I-$ the basis for 1110 alleged Esealplimu.Any violation of Section 7031.5
La by any applicant for a permit subjects the a Bicanl to a Civil STORIES TYPECONST
thanpl penally ALTER-DRAIN VENT-WATER IEA.) 5.00
Of nal marc owner
five hundred Property,
o(5y employees
S '/�
❑ I,as owner of the properly or my employees ... m is not BACK FLOW PROTECT.DEVICE 4.00 ,V
ince sole r oferedlion,will(S the work,and9he and
Pr res,not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. doe business unit n owner.1 DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The h Contractor's is ..IlloLicense Law does nm apply a an owner ul k- 3
/
Property who builds or wn Cuves(Caron,and who dues sued work FIXTURES-PER TRAP 5,00'
IIm!dS far o[in6I1 de own 11cmd tar otar s, le.if, Thal autill IIIIpm W- SD FT.FLOOR An Ea TOTAL ACREAGE
orimprovement nm iis sold willin one'year a.If,howeveq the bei .Crg GAS-EA.SVSTEM•1 1NC.40UTLETS 6.00 6 •7 0-d�
tau ,willhvit sold within one year of completion, the owner- J
pmv of will have the burden of proving(ha ho did not build or it.- GAS-EA.SYSTEM-OVER 4(EA,) 2,00 BUILDING USE
pave for purpose.taupe.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ d as owner of the properly.am ,aceta(Se , 70contracting with p ❑ ❑ ❑ ❑
licensed contraraors to Conle Contractor's
the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 l�_
SOJ Profcssians Cade:'(he Cam ruCl Or s Litt'nse Law dues not apply ASSESSORS PARCEL NO,
to an owner of property who builds of improves Ilaufeml.and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
Contracts I'or such projects will'a Cutaneous)licenxd pursuant m 3 �j 6�-I� (p _ el
'he Cummetor's License Law. SEWER-SANITARY-STORM EA.2001t/10.00
❑ I am exentp'under Sec. ,11..4 N.C.It.Ibis TRACT NO. PARC L NO.
reason WATER HEATER W/VENT 6.00
Owner DulO --
/ WATER SYSTEM 5.00 - I ACC.DATE ACC.FILE N0,
WORKFRS'COMPENSATION DFCLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm Iha' 1 have a Certificate of Consent to.Sell'-insum.
or acertificate of Workers'Compensation Insurance,or a certified ZONING copy Illemol ISOs.3800,Wh.C.). ENG.SITE NO.
policy No. ContpO,,
O ❑ Ccail'iea 'opY is hereby tarnished.
z Z ❑ Cerldir, c rx is tiled with he r' Supe-lien divti mL FIRE SPRINK ENERGY T24
PO Applicals a����01� -t tit'_ MISC.- REFER TO ORD. Y0 N� Y [] N�
CC ti CFRTIF1CAT:OF EXENIFfION P R WORKP.RS _ PERMIT ISSUANCE 10.00 '('J FLOOD ZONE aL.u.c.
LLI > C'OMPENSAT'ION INSURANCE
CL S PLG,CONTR. C.N0. PLG.
handed
donwer...( aced not l'0 Pomp Bled it the pencil ix fur line TOTAL Y N� YE] No
U O hundrad Jolla,(f IUUl or leas.)
I Certify thus in the pcnornunae at [lie work for which phis per-
LD 1- mil is issued,I trill no'employ any person in any nunner w as to GTV' MECHANICAL PERMIT FEE FEE SUMMARY,
0 Lu becmne subject to the Workers'C'unl Pensaliun Laws u1'Culitoodu. /
SO. NOT ICANIan' BUILDING -
F_ N NOTICE TO APPLICANT: II,bj",to lie phis Cerl il'icale of six ALTER OR ADD TO MECH. 5.00
F- Z emplimu,you should become subject to lie Workers Co'npensalbm APPLIANCE
provisions of 'he Lubar Code, you must fuHhwilh comply wish 5.00 PLAN CHECK
U such provisions or this Permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000GF.V0 4,00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000O.EM.) 6.00 SEISMIC FEE Uf
I hereby affirm that there is S con,truc'ion lending agency Iia EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work bar whieh 'his permit is issued(Sec.
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
LCmE•,'S Nante
Lender's Address HEATINGUNITIO VER100,000B.T.U.)9,50 .� Cb
I certify that l have read this application and State that the have VENTILATION FAN (SINGLE) 4.0Q0 0 ELECTRIC
information is correct. 1 agree to comply will)all City and cowry O
ordinances and stale laws ,Elating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6,00 PLUMBING �O 7
hereby authorize representatives ul this city to enter upon the
�'-- abuee-mentioned properly fur ins BOI LER-COMP (Over 100,000 BTU)SEE FEE SCM. ;`-j V-_L
inspection purposes. MECHANICAL
(We) agree 1st save, indemnify and keep hunnless.lhe City of REFER TO ORD.
MISC.-
Cupertino against aliabilities,coajudgnaunls. Cauls Slid expenses which p
nay in any wu accrue a PERMIT ISSUANCE 10.00 CONST.TAX 0 ���
m i I Ux"rt ahs City in consequence of the
muL MECH.CONT.
LIQ NO. MECH.
Sign a tore of Apf icanllContr, sur /Du he - TOTAL �/ TOTAL 7/ 16