C 7206 (2) APPLICANT TO FI1Aj0kN INFORMATION WITHIN RED LIN USE BALL POINT PEN ONLY
;� -
BUILDING PROJECiNTI FICATI PERMIT NUMBER"
BaLLOING APP.LICAT ON& PER ^0^
aonREss /J/J ''77,��� //„„ G b
BUILDING—ELECTRICAL PLUMBING—MECHANICAL
L
OwNER's ,/ PLAN CHECK VALIDATION
p�' 7` NaM'GI i7x I 1 ' LSC TV. ELECTRIC PERMIT FEE
' i.
CONTRAACTORCTOR
/� (y OUTLETS-SWITCHES�RECEP 5.00/1.00 ,
v/H'f bkAF*14 LIC.NO3/11 1I Zj LIGHTING FIXTURES. 5.0.0/1.00
CONTRACTOR5
ADDRESS ' Lhyfg- S- 3D' PPLIANCES
RESIDENTIAL
S
r-At+ PHONE 07,PANELS
-
5.00 DATE OF APPLICATION
OR
- _ - PLAN CHECK FEE P.C.NO.
J OR G� SIGNS, . 6.00
^E EE ^ —SIGNS
- -
l� uc No. SIGNS'TRANS. 3.00'
v
ARCH.SS Etc. 2b� SPECIALCIRCUIT ."5.00MP- _ ALlonnoN
ADA
zlv', TEMP.METER OR POLE INS. 15.00 JUL 9 - 1985
a OnE55
APPLICANT r'S MOTORS SEE FEE SCH.
� I i1� — {( - � � ii� SERVICECHANGE 10:00
o o LICENSED CONTRACTORS DECLAATION �
City of Noertino
R
Q mo U I hereby affirm thw 1 am IioenseA under pnrvisions of Chvpler 0 '- ISSUANCE'DATE .
w rt N femnmencimg with Section 7000)of Division 3 of the tlusiness anJ - - BLO ELECT. , PLG. MECH.
F
N20 Professions Co::((JJ y�l my license is in full far Iy)e F
Z, z m o Licals�,`�(�lass fg_ Lie Number C a -
H Uutc_'4({L�/Q '�Conlrudnr NC6_K.-1 - ..
'a x - BUILDING PERMIT
g ¢ w owNlsR-BOILDIiB DIsc1.A RAnoN - INFORMATION
w ; u r I hereby affirm that-I am Exempt from the Contmcmr's License MISC.1 - REFER TO ORD
LL O¢ Law I'or the followin•reason.(Sec.703 LS,Business and Professions' VALUATION $/FT.
t 1 _ I; PERMIT ISSUANCE 6.00 �)1
Code:Any City or county which requireso permit to construct,alter,
ill l
¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC..CONTH.' LIC.NO. ELEC.
Ea 0 LL lequi res the applic:ull for Such permit to lite a signed statement thal - "c, TOTAL g.
n w m w he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
H z a
Law(Chapter 9(commencing with Section 70000o'Division 3ofthe
4 0 Business and Professions Code)or that he is exempt therefrom and OTY. ,PLUMBING PERMIT FEE
¢ H $ the basis for the alleged exemption.Any viirlot ion of Section 7031.5 - ST/D/gIES TYPE CONSTR.
a
by any applicant fore permit subjects the applicant loacivil penalty ALTER-DRAIN&,VENT-WATER (EA.) 4,00 - / �lll
of rant mom than fore hundred ubjects the ap li i--./ ✓�1 UVJ
❑ Las owner al the property,or my employe s with wages as BACK FLOW PROTECT.DEVICE ' 2,00 OCC.GR uP .RES.UNITS
their sole cnlnpensnl ton,will do the work;and the structure is not -
rate tided 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 sell.does Such W 1k' FIXTURES-PER TRAP . 4.00 FT,FLOOR All EA TOTAL ACR SAGE
himself ar through his awn employees,provided that Such improve.
rents are not intended or offered for Sale If,however.the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4,00
or improvement is Sold within one year of completion,the owner-
bladder
wnerGAS-EASYSTEM-OV ER 4,(EA.) 1.00 BUILDING USE
builderdem will have the buten of proving that he did not build or am.
. - E IND CON PB Omer
prove for purpose ol'suleJ. INDUSTRIAL WASTE INTER. 20.00 "
❑ I,as owner of the property,am exclusively contracting with ❑ E3 ,
, ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO,
and Professions Code:'I'he Contractor's License Law docs not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER'5(EA.) 1.00
' cmenacts for such projects with a contraatons)licensed pursuant to
the Contracmr's License Law. . SEWER-SANITARY-STORM EA.200ftaoo TRACT NO. PARCEL NO.
CI tum Exempt under See ,B.&P C.far this WATER HEATER W/VENT - 4.00
reason
owner Date WATER SYSTEM - 4.00
ACC.DATE ACC.FILE No:
-- , WOBKI;R5'C0MPI:NSATION DISCLARA'rION " WATER TREATING EQUIP. 4.00
I hereby uffrra that I have a cetificute of consent to self-insure, - - ZONING ENG.SITE NO:
or a certificate of Workers'Compensation Insurance,or a certified
CITY N.er y_A��e4B_)&nmy Fit_ Policy I_, .
Z -❑ Certified copy is hereby furnished.
Z Z til' Cetli , sc- d 1• •colon division. FIRE S' NK ENERGY T$4
pPlic:mt_(/���aV/ � �-����S�f�a � MISC.- REFER TO ORD. v ❑' N❑ y ❑ N❑
w PERMIT ISSUANCE 6.00
jr — CERTII'ICCO1 PF SAX ION
ON FROM WORKERS' FLOOD ZONE A.LU.C.
W > COMI',IiNSAI'ION EXEMPTION
PLG.CONTR. - LIC.No. PLG. =
1 O I'fhis sect i<in need not be completed if the permit is for one - TOTAL V❑ N❑,r; V ❑. N❑i
Z hundred dollars(41001 or IEss.)
CO O 1 certify that in the performance of the work for which this per- rFEE SUMMARY
LL b- mit is issued. I shall not employ any person in any manner So as to CITY. MECHANICAL PERMIT FEE
U become Subject to the Workeri Compensation Laws of Calilornia. t Zr
OL Date Applicant BUILDING,-
} of NOTICE 1'U APPLICANT: If,after making this Cetificute of nix- ALTER OR ADD.TO MECH. 4.00 -
2 opinion,You should become subject to the,Workers'Compensation 3 APPLIANCE 4.00 PLAN CHECK
-
provisions of the Labor Code, you must forthwith comply with FEE
Vsuch provisionsor this permit shall be deemed revoked AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONS"I'RU&iON LENDINGAGENCY AIR HANDLING UNIT(OVER 10=C.FM,) 5.00SEISMIC FEE ';.
I hereby atfmn 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 - �
3097,Civ.C.).f. HEATING UNIT(TO 100,000 B.T.U.) 4.00 o-
Lender's Name HEATI NG UN IT(OV ER 100,000 B.T.U.)7.50 I'3 D
Lender's Address E CTRIC
I certify that I have read this application and sante that the shove VENTILATION FAN (SINGLE) - 3.00
r information is correcL.l agree to comply with all city and county PLUMBING ,
ordinances and Stahl laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4,00
hereby authorize representatives this city es enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEESCH. MECHANICAL' 3
above-mentioned property for inspection purposes.
'(We) agree to Save, indemnify and keep harmless the City of MISC. f - REFER TO ORD.
Cupertino against lie ilitie,judgments, costs and expenses which - PERMIT.ISSUANCE 3.00 CONST.TAX W
may in ay I -rue Inst said City in on balmoce of the -
gran ' I: a lit. MECH.CONT. 'LIC.NO, MECH..
O TOTA '
na eon pplleant(Contractor Datef/l( lq[/✓1
` - OFFICECOPV