14732 (3) APPLICANT TO FILL IN, INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
n`• BUILDING PROJECT lDENTI FICATION ' PERMIT NUMBER'APPLICATION & PERMIT
TRUING _ . 14 7 3 2
noon Ess gUl LDING - ELECTRICAL-PLUMBING-MECHANICAL
22304. Re oast Rd. _
OWNER
PLAN CHECK VALIDATION
NAME .PRSN, 252-7,750 QTY. ELECTRIC PERMIT y FEE
NAME acT s UTLETS SWITCHES RECEP 10.00/1,00 �d
LAC NO.- LIGHTING FIXTURES 10.00/1.00
' r
CONTRACTORS '
ADDRESS APPLIANCES;RESIDENTIAL-" 4.00 • - t
PHONE �• 'PANELS 10.00 -� DATE OF APPLICATION ,
Ogcmnecr, - "'PANELS (OVER 200 AMP) 20.00 �f PLAN CHECK FEE P.C_N0.
ENGINEER -
' uc.No.' SIGNS TRANS; 3.00 t
OR ENG.
ADDRE $PEEIAL CIRCUIT. 5.00 PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 20.00
APPLICANT
PP ICA TS . . MOTORS - SEE FEE SCH.ADD �-Q-
/�
22322 Re n t -Rd. SERVICE CHANGE 20.00
0
0
y
F o D' LICENSED CON'1'0.ACTORS DIiCLARATION _ Yar !°
a u o I hereby afrin that I am licensed under provisionsof Chapte") ,
Z
(commencing with Section 7000)of Division 3 of the Ilusiness and ++s� ISSUANCE DATE'
H N z Professions Code,and my license is id full forte and effect. - g +j BLDG.. ELECT. PLG... MECH.
¢ 0 m w License Class Lie Number r.
4 Dale tr
- Conactor - ��� • - ❑ . " 7 ❑ 11
Q y E J ..
¢ rs w ¢ OWNER-I)UIIAER UI_CLARA'I'1 ON - \x1\Y ..:0 \�3 _ BUILDING PERMIT
MISE.- REFER TO'ORD INFORMATION
w ; u_H 1 hereby affirm that I am exempt from the Contractor's License • - ,-� -
u O Lnw I'or the following reason.ISec.7031.5,Nosiness anA Professions VALUATION $/FT.
r - PERMIT ISSUANCE ('�\W7 ` ''10.00 Q'-
Ic w>E improve,
Any dry or county whiny structure pennil tocons construct,alter, Y t
K M ¢O improve,demolish,or repair any structure,nature,prior to its issrianCc,also ELEC.CONTR. LIC.N0. ELEG 30
'G u re,sires tIta applicant I'or such permit In file a signed sl u l emenI that / r TOTAL
e w m he is licensed pursuant to tilt provisions of the Contractor's License PERMIT TO
Law(Chapter 9(commencing with Section 7000)OfDivision 3 ofthe
f i a Business unit Professions Code)or that he id exempt therefrom and' CITY. PLUMBING PERMIT FEE
ic r$ the basis Rai the alleged exemption.Any violation of Section 7031.5 - - STORIES TYPE CONSTR.
d ; - by any applicant for.,permit subjects the applicant too civil penalty ALTER-DRAIN -WATER IEA:) 5.00
.(,,of more than five hundred dollars($500).):
Cl 1,as owner of fire property,•or my employeeswith wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP AES.UNITS'
their sole coni+ensation,will do the work.Turf st incline is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
_ - Code:The Contractor's License Law docs not apply to an owner of-
property who builds or improves thereon,and who data such work FIXTURES-PER TRAP ,'�, S.00 50.FT,FLOOR AREA.- TOTAL ACREAGE
himself or through his own employees,provided that such improve- -
mcirsure not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00 .
••if or improvement is sold within one"at 01 completion,the owner. - -
builder will have the burden of proving that he did not build or im- GAS-.EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE -
proveforpurposeofs:deJ. INDUSTRIAL WASTE INTER.•' 30.00 RES IND CON RB . Omer
V R' I,as owner of the property,arm exclusively contracting with
licensed contractors to construe the project(Svc, 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
-- and Pml'eseions Code:'floe 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 contractions)licensed pursuant to
the Contractor's Liccnm Law. • SEWER•SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ tum exempt undersea -,tl.&P.C.I'or this WATER HEATER W/VENT 6.00 ' '1
Owner
Owner ) Dafe WATER SYSTEM5.00 ACC.Dare' ACD.FILEENO.
W(111x'I
.RS'COe 'ENSATION DECLARATION WATER TREATING EQUIP. 5.00 -
I hereby affirm that 4 have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE N0,
copy thereof(Sec 3800,Lab.C.).
Policy No 0 Company
. 0 . ❑ Certibed copy is hereby furnished. - - FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division.
F O Applicant MISC.- , '. REFER TO ORD. Y N v N[_
N CERTIFICATE OF EXEMPTION 17ROM WORKERS' PERMIT ISSUANCE, 10.00 FLOOD ZONE . A.L.U.C.
a W > COFIPFNSATION INSURANCE PLG.CONTR. UC.NO. 'FLG.'
CL O Has section need riot be conmletc,l if III, permit is for one _ TOTAL Y,❑ N 0 Y ❑,' N❑-
Z hundred Aollars IS 100)or ISA.)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,1 shall riot employ any person in any manner saps to .
become hjeq to the Workers'Cot ti ..Iyy�n' allloa ia. _
-• y Dafc2i.ldTnpplicxm��' - ALTER OR ADD TO MECH. ' 5.00 BUILDING
N NOTIC: 'f APPLICANT: II', far m This •erlificelcoffix-
,F ? emprion,yon should become subject o the Workers'Compensation APPLIANCE _ 500 PLAN CHECK"
Provisions of the .
Labor Code, you must forthwith comply with '
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000GF.M.) 4.00 FEE
CONSTRUCTION L17NDING ACIiNCY AIR HANDLING UNIT(OVER I0A00GEM.).6.00 .SEISMIC FEE
I hereby affirm that there is a construction lending agency far EXHAUST HOOD (WITH DUCT) . 5.00
the pefloRcmme of,lhe work for which this permit is issued(Sec. - '.MICROFILM
3097,CN.C.). HEATING UNIT(TO 100,000 B.T.U.)' 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's nddmss - v .)ELECTRIC
I'certity that I have read this application and state that the above VENTILATION FAN (SINGLE)' 4,00 .,
t infsrtnatlou is correct I agree to comply with all city and county xPLUMBING
ordinances and state laws relating'ho building construction,and BOILER-COMP(3 H.P.or t00,0006.T.U.) 6.00 ' _
t above- eu[horite representatives ins Of this city es cot's upon the BOILER-COMP (Over 100,000 BTU) FEE'SCH. a MECHANICAL
!t hen ,. mitioned properly for inspection purposes,
"-(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgnants, costs-;rod expenses which _ ,CONST.TAX
may in any way ace a against said City in con trounce of the ' PERMIT ISSUANCE 10.00
r
anti of[his MECH.CONT. LIC.NO. MECH. y
3 TOTAL' . . i TOTAL
Nigignat cofA .=ant/coal cfor
Dat r
„ OFFICE COPY '