14550 (2) APPLICANT TO FILL IN INFORMATION INITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT 1 DENTI FICATION PERMIT NU•MEER
atr�LG,NG APPLICATION & PERMIT 1 X550
AcuasESs _
/Q1� IZlDr- C VmFw GT. BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
OwhLN'S JLANCHECK VALIDATION
O7Y. ELECTRIC PERMIT FEE
/TA eDhE
CarauurORs QC'A1Qy OUTLETS-SWITCHES-RECEP 10.00/1.00
NnAI! /
Sc�7T- n 485568 LIGHTING FIXTURES 10.00/1.00
_OOFIESCroHs (�,/Jc� !APPLIANCES-RESIDENTIAL 4.00
-:. /'?,9 14A2K&T51 Z333 IPANELS 10.00 DATE OF APPLICATION
A.CHIrECT IPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.c.Nu.
OR 0 ISIGNS TRANS. 3.00
anC]..OR ENG, SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
oCRESS
to EMP. METER OR POLE INS. 20.00 �)
APPUCANT's IMOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION
r y I hereby oflinn that I ten licensed under prm iaiufu of Cluptnr 9 ISSUANCE DATE
I:onun I'Ll",with Section 70001 of Di wit. 3 of the Bmfncss and BLDG. ELECT. PLG. ME'ja.
r J'i Plot...too,Code.YIJ oy lieabe is In lull Id"'.]nit 'l l' t ❑ ❑ ❑ r�'1
Li:ens,Cl i GNt_1Of��Li:.Number=l-$SSy9 LJ-
17ate Collnauor
se >` J OW'N'ER-BUILDER DECLARATION BUILDING PERMIT
d ¢ ❑ F REFER TO ORD INFORMATION
x 3 E. I hereby iiinn lila I sun conn t iron the Con tractor:Liccmc MISC. -
y a p VALUATION 'FS/FT.
.. 0 el Law for the foilowing«uson.(See 7031.5.B.,i....And Proievmns PERMIT ISSUANCE 10.00
Code:Any coy lir eounly which requires Permit to ronetmat.alter.
u S ¢ improve.Jcfnullsh,or repair any structure.prior to its issuance.also ELEC.CONTR. LIC.NO. ELEC.
E
¢ re4ui es the applicant for suds permt it to rile a>igneJ awoor that TOTAL PERMIT TO
he is licensed pursuant to the provisions of life Cuntraclor's License ,f,T
rAs Law(Chapter 9(confmoneing with Section 7000)uf Division 3 ofthe
f ¢ a Business and Pruicoions CoJu nr !flat Ile is exempt tharcfwm aid DTV. PLUMBING PERMIT FEE
r the basis fur the alleged e,enlp,wn.Any'violut ion ill Section 7031.) STORIES TYPE CONSTR.
¢
b) Any upplicuntto,a perndt aubjec¢the appliaunt in A'I'll penally ALTER-DRAIN& VENT-WATER (EA.) 5,00
of not more than five hundred dollars l SSOU).I:
C'I,as owner of(he property.or Iny empicoces with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will Ju the work.and the oruciare is not
intended or offered for sale (See 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
. Code: The Contractor's Licasc Law dues nut apply to a]owner of
property who builds or Improves!hereon,and who Joc.such work F IXTURES-PER TRAP 5.00 S0.FT.FL008 AREA TOTAL ACREAGE
himself or through his own employee,.provided thatsu:h improse- GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
1 mems are not intended lir otlered fur sale.If,however.the building
i 0r imp]ovemma iswld within one year of completion,life owner GAS- EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will!lave U]e harden of pravmg tlut he did nut build or inn- RES IND CON PB Ome.
prove for purpose of sale.). I NDUSTR IAL WASTE INTER. 30.00
❑ I,as owner of the property,ams c\chaivcly ten nae,ing with
fee road coon'"O" to C.nvruct the odi"l(Sec. 7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License Law does not apply
to an owner of properly 'wild builds or improves thereon,unit who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for Mich prnjeels will]a cwane(uns)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
❑ lam uennpl under Sec. ,B.&BC.ILr
it, WATER HEATER WIVENT 6.00
rea>On
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERSCOMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affil. that I base A eenificac of con>aa to lel Limure. ZONING ENG.SITE N0.
nr a ccmfw.te of Workers Compensation Insurance.or a certified
Copy thereof(Set.3B ¢b.C.l.
Pon-S'N./1.TQ7L�pTC$7Rpony.
Q ❑ Cmolcd copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z C Certified copy is tiled with the city Inspection division. MISC.- REFERTO ORD. Y(-] NY [] N�
Applicant
RMIT ISSUANCE 10.00
~ ��
� - 10ERllFICa1TEOP EXEMPTION FROM WORKERS.ORRERS' PEFLOOD ZONE A.L.u.C.
W > CO.MPIi NSA'pION INSURANCE PLG,CONTR, LIC.N0. PLG. Y N Y C] N
d O (This section need not be con bleled if the Penn it is Nor one TOTAL
Z hundred]dollars IS UOlur less.) QQ
V O 1 ecrtily that in the perfurnance of the work for which thin per Y MECHANICAL P2RMIT ��� FEE - FEE SUMMARY
LL H mit is issued, I shall ala employ'any person in anm
y unna cr so to f
O w become subject to the Workers Compensaliun laws of California. BUILDING
Date Appfieunt ALTER OR ADD TO MEC0.
I'��
} 0 NOTICE TO APPLACANT'. It,atter talking this Certificate of Ex-
F Z CIIIPtlon,you should become subject to the Workers'Compensation APPLIANCE V .00 PLAN CHECK
provisions of the Labor Code, you must forlhwith comply with FEE
V such provision,or this permit Shull be duuncd revoked. AIR HANDLING UNIT ITO 10 .M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.EM.) 6.00 ,00 SEISMIC FEE
I hereby affinn that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the perlunosnce of the work for which this perMt is issued!See MICROFILM
3097,Civ.C.). HEATING UNIT ITO 100,000 B.T.U.1 8.00
Lceder',Name HEATI NG UN IT(OV ER 100,000 B.T.U.19.50 ELECTRIC
Lcndc,'s Add....
I certify that l have read this application unit state that the ahooe VENTILATION FAN (SINGLE) 4.00 2,9,(2 01)
infonnmion is correct. I agree to con]pty will,all city and countyBOILER-COMP(3 H.P,or 100,000 B.T.U.) 6.00 PLUMBING
ursordnees and stale laws refuting to building construction, and
sAlmhereby outhurin rcp...entmives of this oily to enter upon the
above.mentonedgrmuperty fur onipectim,purpose>. BOILER-COMP IOvnr 100,000 BTU!SEE FEE SCH. 4Q,Po MECHANICAL 475'0
(%le) agree to suve. iride wmty and keep lurndess the City of MISC. REFER TO ORD.
Cupertino agains, liabilities,judgfncnti, coats and expenses which PERMIT ISSUANCE 10.00 YO CONST.TAX
tory in any way accrue eg'vinnN Aid City in cm]uyuentt of the
•ranting ill this p' I nit. MECH.CONT. LIC.NO, MECH. N
/-27-8, TOTAL 410 TOTAL
i Signatur4 of AppheanUCunlruetur Date
INSPECTOR COPY
APPLICANT TO FILL IN INFORMATION VVITHIN RED LINES - USE BALL POINT PEN ONLY
_11q1 IT
N",ER
6U ILD ING PROJECT I DENTI F I CAT(ON APPLICATION & PERMIT 1 / 550
a.aohnc
AooNEss BUILDING - ELECTRICAL- PLUMBING -MECHANICAL
(:� K1 SSE IIIEW CT.
PLAN CHECK VALIDATION
_ OWNLHs
QTY. ELECTRIC PERMIT FEE
D/6/T!� DNE
oNTnaCTORS )'/�k1Ay OUTLETS-SWITCHES-RECEP 10.00/1.00
4,44,E I . 4355 60
LIGHTING FIXTURES 10.00/1.00
ConRrnaaoN's ,Qy/51 IgpPLIANCES-RESIDENTIAL 4.00
ADDESS Oj�
14AK�n 'rK&T 5/- PnuNE 4- PANELS 10.00 DATE OF APPLICATION
ANcnrEnT
PANELS (OVER 200 AMP) 20,00 PLAN cnECK FEE ? ND.
OR
ENGINEER SIGNS TRANS. 3.00
LIC.NO. PER M1IIT VALIDATION
A.C..OR Enc. SPECIALCIRCUIT 5.00
ADDRESS
zlP EMP.METER OR POLE INS. 20.00
PPUCANT's MOTORS SEE FEE SCH.
AUONE55
SERVICE CHANGE 20.00
W� =
O o
LICENSED CONTRACTORS UEC'LA R,\TION
F hereby aifirhn That I am lie<naed under proskium of Chapter l ISSUANCE DATE
� ' Il:Ohmm�lcing with Section 70001 of O'nllino 3.I the Business and BLDG. ELECT. PLG. InEE^��I.
< „ ❑ ❑
O � PTot..,Ions'-ode,' ,r, ieenw is in lull l.r,,,mdoC/
i oF]r=-�ILixnu Clas�4j.,Of�'j-Lia Nmob<r_ /../I--'''T-
o w Date Contractor
BUILDING PERMIT
a a �`¢ a O\VINER-BUILDER DECLARATION INFORMATION
E . MISC. - REFER TO ORD
`x A 1 for Li aftlrn ' , am rue. 7 iron ILL:Canton r\f,"Itne vA WaiION 5/FT.
-a Law for The ily.1 ng lee Rilich c n"c",Dminc„cons ru aiu11s PERMIT ISSUANCE 10.00
p i Code:An) city ur county which rccpntcsa Penni'm isconstruct.
-ua .also
ELEC.CONT R. LIC.NO. ELEC.
u ¢ a p intprove,demolish,or repair any suuctur<,prior I., isawnn'.abo TOTAL PERMIT TO
D Q rv4uifes the applicant or such permit w till a signed'al"ne t thio
' u m he is licensed Punmmr to the pronsions of the Contractor's License AA �J
`-c v
rzi Law"'i,per 91 mnunencingwnh Section 70001of Division 3 of the PLUMBING PERMIT FEE /'/
4 BoA, [»And Plot ..IUln Cody)or that Ile n"i'ltpt thl"Iral'a Lad CITY. STORIES TYPE CONSTR.
r o the basis Pur tlm ullegnl c,lm,timl Any violutimt ui Section 7031.5
Ate _ by any applicant for a pcnnil.uuieele thc'pPllCuol ma Cl"perlalty ALTER-DRAIN -WATER IEA,15.00
of not Ino,,titan five hunJre•J dollars IS500)1:
❑' 1.as owner of the pulpert,or..y ea,P1oyce,with wages'm BACK F LOW PROTECT. DEV ICE 4.00 Oce GROUP RES.UNITS
Uteir sole caopensatlln,will d.The work.and [lie struCtwe is not AREA,[OND. 5.00
nen Jed or oil'red kyr all (See 7041 13.,111111 and plifle,siuos DRAINS-FLOOR,ROOF,
Code:The Call l...for s Lelnw Law dc,,oot apply'to a,I.wnrr of S,BO SO,FT.FLOOR ANSA TOTAL ACf1EAGE
property who builds or int proses thercun.and wow does one"work F IXTUR E$- PER TRAP
hinueli or through hit own<mployeo.prollJcd that such lnlprovo-
GAS-EA.SYSTEM-11NC.4 OUTLETS 6.00
men's are no.intended or.filled for sac.It',h.wevvr.the bulldinp
•t� or improvement i1 sold within one year ut cons Fiction, the owner-rGAS- EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will Ili,.the hlyden of p,clin,that ill did not Isuild in,- RES IND CON PB Omer
prove for purpose of sale.I. INOUSTRIALWASTE INTER. $0.00 0
❑ I,as owner oI he pmpsnp.ant csclus)vely emHra,Img with
licensed ron0actnrs I. : nxract de pr,,cl(Sec 7044.Omine,s LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 HESE BSORB PARCEL NO.
and Prolegitns Coda•:The Convu,Eur's Liceaw Law duos nut apply
to an owner of motility who builds or imprme,thercun.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for luck projects with a contractorllt Ilumw•d pursuant w SEWER-SANITARY-STORM EA.200fi/10.00 TRACT NU. PARCEL NO.
,he Contractor's License Law.
❑ tum ea.•mp'undcr Sec. .BdY.C.North" WATER HEATER W/VENT 6.00
f
Ownc, Dull WATER SYSTEM 5.00 ACC DATE ACC.FILE NO.
nu
N'ORKERS'CO.\IPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby ofirm 'ha, l hone ac<nificaln of conxn'to self-insure, ZONING ENG.SITE NO.
or a .crt1hcae of R'urkus'Compensation Imumnle.or a senifieJ
cop)' her 'Sec.3g.n�T b.C.).
Pohcy N.LY:6N.6ZL kl4ny-ZNrr/+
C) 0 Cerlltmd cup)'is ht•ra'by turnish[J. FIRE SPANK ENERGYT79
Z z 0 Ccnllicd copy is Iiled with 'he lily inspection Jisision. MISC. - REFER TO ORD. Y IN v 0 N :
1- � : Applicant
! PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.c.
- 1 CERTIFICATE OF EXEMPTION FROG\I N'ORAERS'
LU COCIPEN'SATION INSURANCE PLO.CONTR. LIC.NO. TOTAL Y❑ N❑ Y ❑ N�
CL O (1'hi, wctian need .,or be cons PlemJ it the par11tit is for one ��YY
� Z hundred d.tlars(SIUUlor lay.' �C) FEE
ImFEE SUMMARY
O O 1 l,tily that in the pertunnance of the work for which Ellis per MECHANICAL P RMIT'• `
LL H o is issued.1 shill not employ any Pcrson it any planner so as to
Ou Iwcomewbject to the w'orke,NCmnpensao.n Law,of Cnlifmai+. BUILDING
Ed o. Ua'e Apph"I'l _. ALTER OR ADD TO MEC
} ti NOTICE TO APPLICANT: IL alio, making 'his Cendlcatc.l Ea- .00 PLAN CHECK
F Z emptlom You llluwd bcc.ntu s.hieel to the workers'Cmuponsar ion APPLIANCE FEE
provisions of the Labor Code. you into, forthwith cmnply will) AIR HANDLING UNIT(T 10 .M l 4.00
C„) such provisiom or this permit shall be deuned revoked.
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10A00 C.F.M.) 6.00 .OD SEISMIC FEE
I hereby a0irm that there is a CO"Tioon lending ngemy for EXHAUST HOOD (WITH DUCT) 5.00 MICROFILM
the rerturmunce of the work for which this permit is issued(See. HEATING UNIT(TO 100,000 B.T.U.) 8.00
3097,Ov.C.).
Lcnder's Name H EATING UN IT(OV ER 100,000 B.T.U.19.50 ELECTRIC
Lender's Address 4.00 rs6 U
Icer'lly tlullluvr real this apPliwiun and state that the ahtva. VENTILATION FAN (SINGLE) PLUMBING
v Infonnawnl i, current. I agree to comply with ill eI,, and euuNy BOILER-COMPQ H.P.or 100,000 B.T.U.) 6.00
.v
urdinsacs arid! state laws rclming .. building curovuc,iun, and
hereby aullmli,e reproenla'rves of ins cit1. .,,let upon the BOILER-COMP (Over 100,000 BTUI SEE FEE SCH. 40.00 MECHANICAL }'YU
above-memiuned property for inspection purposes. REFER TO ORD.
(we) agree to save indema,ty and keep harmless the Cit.1 MISC.-
upanmo against liabilities,judliell-s. Cnu,and .,Tenses whin' 10.00 CONST.TAX
may in any way acerin against said City in ronseyucnce of the
PERMIT ISSUANCE /u
ranting of thi, roil. MECH.CONT. LIC.NU. METH. f,)
�. 1-217-03roiAL [/o TOTAL
/ Signature aApphunuConlneWr Date
\!� INSPECTOR COPY