18233 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED.LINES- USE BALLPOINT PEN.bNLY
PERMIT NUMBER
BUILDING PROJECT IDENTIFICATION
no Lot..-
APPLICATION Sl PERMIT - G
ADDRESS 18-233
- Z.. s- �V BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S .. PLAN CHECK VALIDATION
N{A)��MEE �' r OTY- ELECTRIC PERMIT FEE. - PAID -'
/�/, GCJ' LJ'NONE ' APR. 1e
V CONTRACTOR'S; _
NAME OUTLETS-SWITCHES-RECEP 10.00/.1.00
Ll Ff�(u-C C>� Ofl�S pLrc�.No,Z .-.CB Z LIGHTING FIXTURES 10.00/1.00 N ,
CONTRACTDRsq �1u2 n/ti0 /�'L APPLIANCES-RESIDENTIAL 4.00 r
A(o�oREss
fir}{, / c4t,at Cj�t►'!MI .
I �1 N/� NI\ lNY'ONE' qL•(-(O 1 PANELS_ -10.00 DARTIIE OF APPLICATION
ARCHITECT PLAN CHECK FEE PC.NO.
PANELS (OVER 200 AMPI 20.00 M
ENG EEO / / q /
OR &J 6 "e aV-10 No. l9 ^� SIGNS TRANS. 3.00 76, Fy T tl
-
ARCH.OR ENG. SPECIAL CIRCUIT � 5.00 PERMIT VALIDATION
G 'ZIT• rrEMP.METER OR POLE INS. 20.00APPLICANTS MOTORS - Z-•• SEE FEE SCH. /61. 00
ADDRESS p , '
/O o%v N;0) go SERVIC G 20.
o o LICENSE:[)CONTRACTORS DECLARATION �' ' �s$�(y��s�EEfE//��.
diet I hereby affirm that I um licensed underprovisionsof Chapterr) W I$$U#NCE�R%E
a [commencing with S.eti n 7000)of Division 3 of the Business and (/� LL
�n rt - ' �y/ \/-11/, op W- BL ,ELECT. PLO. MECH.<
r N i Professions Codc,pq 1 n :cense is in full force a d eThe y' ->`__
z o m- Licens Number "2 J 8 Z' K�
_ m r w Dom 4g Contacmr' s,
p z D �� � �-'1"��� } r - BUILDING PERMIT
y ¢ a OWNER-BUILDF,R DECLARATION
��
s o a INFORMATION
w 3 LL H I hereby affirm (ha. I am exempt form the Cnntraaor's License MISC.- REFER TO ORD
703 VALUATION $/FT.
HmwJ Law for the following reason.(Sec. uiresa,ermit to
Professions PERMIT ISSUANCE _ 10.00 rO(1
Code:Any molish oreotinly
pair any structure permit pmsuace,lter,aro �'Z �"Jt)h
p improve,demolish,m repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. �.•� J vV
O K requires the applicant for such permit to file a signed statement that r TDTAL .3S O V
u w m" he is licensed pursuant to the provisions of the Con(racon s License - - PERMIT TO^ _
Hz i Law(Chapter 9(commencing with Section 7000)o(Division 3athe (vu,"
�V
E i a Business and Po,feWons Code)or that he is exempt Ilmoefrnm and DTV. - PLUMBING PERMIT FEE T
M -m the basis for the alleged exmupfrrn.Any vieluti.e.(Scotian 7031.5 - j STORIES - TYPE CONSTR.
a 3 - by any applicant far a Permit subjects the applicant lou civil penalty
'
of not more than five lundreddollanr($500).): ALTER-DRAIN&VENT-WATER-(EA.-) 5:00
❑ 1,as owner of the properly,or my employcts with wages as
not BACK F LOWuPROT ECT. .
DEVICE 400
their sole compensation,will Jo the work,anti tile structure is d OCC.GROUP REB.UNITS
intended Sr offered for sale (Sec. 7044, Business and Professions. DRAINS-FLOOR,ROOF,AREA,CONIC. 5.00 -
Code:The Contractors License Law does not apply to un owner of -
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT:FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that rl;Clr improve- -
arentsare not intendMoroffered forsale.If,however,the building GAS-EA.SVSTEM-11NC.40UTLETS 6.00 <�O
or improvement is sold within one year of completion,the owner- j
- / c builder will have the brdden of proving that he did not build or ins- GAS-EA:SV STEM-OVER 4 (EA.) 2.00 BUILDING USE
' •" prove for purpose of sale.), RES IND COµ PB Other
❑ I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER.- '30.00 •'❑ ❑ ❑ ❑
r licensed contractors m construct Ire project(Sec. 7044,Business '- LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSOR PARCELNO.
and Professions Code:'I'Ite Cnnlractor's License Law does not apply
to an owner of properly wino hailds or improves Ihercon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200(t/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&I'.C.for this WATER HEATER W/VENT6.00
reason
Owner Date WATER SYSTEM- 5.00 'ACC.DATE ACD.FILE NO:
WORK E RS'COM PE:NSAT'ION DECLARATION WATER TREATING EQUIP 5.00
I hereby uIfnn that 1 huvu'a certificate of cans....t.suit-insure. _
or a certificate of Workers Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy theieoffsec.3800,Lah.CJ. -
Policy No. Company `
0 O Far red ca py is hereby furnished.- FIRE SPRINK ENERGY T-Z4
pea
Z Z Certrfne y is ded with the'c' insn iJ
FO Applicant _ MISC.- REFER TO ORD. Y ❑ N❑ I Y ❑ N❑
CCW CI.RTII'ICATI;OPIiX[zMPT10NFRONIWORRIiR.• PERMIT ISSUANCE 10.00 lrZ ten FLOOD ZONE A.L.U,C.
LU - CONI'I:NSATIONINSURANCIi r PLG.CONTR: - LIC.NO. PLG. p� ^
CL 0 ('Phis section need not be completed if the permit is for one - TOTAL I �' �V Y❑ N❑ Y ❑ N❑
Z) Z . hundred dollars IS 100)orless) - -
U O 1 certify that in the purfonnance of the work for which this per-, QTY. . MECHANICAL PERMIT FEE FEE SUMMARY
LL•U orit is issued,1 slid]]not employ any person in any mannerso as to -.
become subject to the Workers Compensation Laws n1'Culifornia.i
DO - Date Applicam ALTER OR ADD TO MECH. r 5.00 BUILDING
} 0 NOTICE TO APPLICANT: If,after making this Croificute ul'Ed-
Z emplion,you should become subject to Ire Workers'Compensation APPLIANCE 5.00 PLAN Cr
provisions of the labor Code, you must forthwith comply with - FEE
U such provisions or.his permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,00041F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE + 6U
I hereby affirm that (here is a construction lending agency for EXHAUST HOOD (WITH DUCT). 5.00 .
the performance of the work for which this Permit is issued(Sec. MICROFILM
3077,Civ.C.L HEATING UNIT(TO 100,000 B:T.U.) 8.00 '
Lender's Name - HEATI NG,UN IT 100;000 B.T.U.)9.50 3SS'v
Lender's Address - ELECTRIC
I certify (het I have read this application and state that the aboveVENTILATION FAN (SINGLE) 4.00 -
information is correct. I agree to comply with all city and•coun(y PLUMBING
ordinances and state laws relating to building construction, and BOILER-CDMP(3 H.P.or 100,000 B.T.U.) 6.00
honey authorise representatives ins ec this city 4r enter .mon the 801 LER-COMP (Over 100,000 BTU)SEE FEE SCH, MECHANICAL 43 00
�+�" above-mentioned property forinsp of
purposes,in.
(We) agnee to save, indemnify andkeep,lora is the City of MISC:- REFER TO ORD.
Cupertino against liabilities,judgments, coshs .fill expenses whichpERM1T ISSUANCE - 10.00 CONST.TAX
_ may in any-way accrue against said City in consequence of the (/$r•
ranting o histi MECH.CONT LIC.NO. MECH.
TOTAL,
Signature ' 'p TOTAL q (d
Signature of Applicant/Contactorctur - Dal � �' - � ? �� I
OFFICE COPY