15494 (5) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATI ON .PERMIT NUMBER
BUILDING APPLICATION & PERMIT q n
'ti..
ADDRESS I `�
ES I j 9 _��) 6 B DING - ELECTRICAL-PLUMBING-MECHANICAL
AMEOwlsltisC41A= ( t- r•-}Cl(.0, 'fdG PLAN CHECK VALIDATION
• DTV• ELECTRIC PERMIT FEE
Vu�'r• NAMpRAcrOR's OUTLETS-SWITCHES-RECEP 10,0011,00
i!E7+0. ! J 1 LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S
\ ADOREss " PPLIANCES-RESIDENTIAL 4.00
3 j �C �' /l/ -?NONE _ J -'=`�. PANELS 10.00 DATE OF APPLICATION
OR
AD PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0.
ENGINEER
AJZ ir UC,NO. SIGNS TRANS. 3.00
ADDDRESS ENc' SPECIAL CIRCUIT 5.00 - PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
0¢ z
-02 LICENSED CONTRACTORS DHCLYk A'1'ION
a u)J I hereby aUj,r, that I ons)i cen,.I under provisions of Cliapt"9
z w ISSUANCE DATE
„ ¢ N (commencing with Seen.. 7000).f Division 3 DI Ihr B.siness amt SLOG. ELECT. PLG. MECH.
r H z\ Professions le,and m liey�tie rs in lull Wn W cl I. 1:1
❑ ❑
o i m o l License Cluw"r Lie Number
H 4 t: ./ Date ,C "_Comm'[.";
¢ x s tILDING PERMIT
K a w ¢ OWNEILBUILUIiR❑EC'L,112ATION
o A U ;� INFORMATION
K
; w 1 hereby collo that I am eaec.pl Gam the Contractor's ro License MISC.- REFER TO ORD
u O j Law for the follow reason,(Sec.70.11.i,liusin'ss and I'minsimu VALUA S/FT.
- PERMIT ISSUANCE 10.00
f it 4
Code: ,,dory or clmty it ,,req our,POl minor,nalnmt,all'.
R ¢ ¢ impl4o',,Jenwlisll,or repair unY,Im41un',prim I.it,isaunrr,at,. ELEC.CONTR. LIC.NO. -j
ELEC.
O ¢ rcyuircs
tire appIh,,nl In,such Permit to lite a signet,Wtenurj that TOTAL PERMIT TO
w m he is licenser pul%lanl I.the provisions of(be C.ntra,pn's Cie,Iur
riQLaw(Chapter 9(,.1......rical,with S,aion 7000)of Uivisiun fol ill,
z 0 Bolin,,and Noleealons Code)or out he is,,,,npI Ol,roroul and CITY. PLUMBING PERMIT FEE
x I-$ Ill'basis for Ill,alleged riemplinn.Ali,violalion of Socll.n 7031.5 STORIES TYPE CONSTR.
b>.any upplicanl for,"'noir aubiell,]be applicant"a civil Penally ALTER-DRAIN -WATER (EA.) 5.00
.final nwre floorlis,hundred doliurs LSi0U1.,:
❑ I,as.wrier of Ibe pnlp.rt,.nr Illy enhpluy.•rs wish cosset as BACK F LOW PROTECTDEVICE 4.00
their,ole 4.Iriprn,alion,will Jo the x'.ok.and the 11 H, ore is nal . OCC.GROUP RES.UNITS
intended .1 Ilfe,,d for sal' (S,,. 7044, Rmiuvs. and Pore almis DRAINS-FLOOR,HOOF,AREA,COND. 5.00
Code:'The Contractor, License Luw Jon not apply m un nwI
nrr.
propels who builds.r improves thereon,and who Jots ouch work FIXTURES-PER TRAP 5.00 so.FT.FLOOR AREA TOTALACREAGE
himself or 161ougl, b,-11,ehuploJ'aE•a.Provided 16v web improsr-
• mems are nm intended urolhred lors,le.H.llowrsr,.Ihr building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or ins Pruvenlent is sold within one yt,ar of ennlp[olhon,the owner.
GAS- EA.SYSTEM-OVER 4 (EA.) 2.00
builder will Plast,urpose
the burden ul prm'Ing that he did not buil)or int- BUILDING USE
prove fora,-woer of the.1. INDUSTRIAL WASTE INTER. 30=1RES IND CON Pe Omer
❑ d as nwnrr of the properly'.am prject(Sec.
704 , illswqJjonell ❑ El 0 0 ED
and profession,ssion,Code:
: le Contranoct Ihr project ISec. does of ipl°as LAWN SPR IN KLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Proicssioro('ode:'fhe Contractor's License Law duos not apply'
to an owner o1property who huilJs oI improves Ihamnn.lull who LAWN SPRINKLERS-OVER 5(EA.) 1.00
1.11111111 for such Prulecls with a comr,te orts)licensed pursuant I.
the Contractor,License Law, I SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I con esrhupl under Sec IL&I(C.ILr Hlia
reason WATER HEATER W/VENT 6.00
OwII'r IJale WATER SYSTEM 5.00 ACC.GATE ACC,FILE NO.
W tKI::kS',/'1COM!P iNSA'I'ION�+D�E��CjjLARATION' WATER TREATING EQUIP, 5.00
c
Iy -im_?.Ai /rate:SesMi�Jt<uGEewi�. mcell=;mere,
or a ceniIMa R•of Workers'C'ompe sat ion Insurance,or a certified ZONING ENG.SITE NO.
cyy��yyyy Leol'(Sec.3500 Lab C)
1'oCI Cnier,b y l(�
Q ❑ C, I'l."il 'spy whereby urni,lled. FIRE SPRINK ENERGY T-24
Z 2 ID/Cenilk Py '11kJ iib la city�IkkS'
O Applicant _,- .. �.R_�. � _ MISC.- REFER TO ORD. y N� Y No
CCN axnFICyTE OF EXIi,MPI I(yN FROAPERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U,C.
W � CO.\ll'INSAPION'INSUk ANPLG,CONTR. LIC.NO. PLG.
CL o (This lection need our be 4ompl,IeJ it the prnnil is lar one TOTAL Y C] N[D Y C3 RE]
C.3O hundr,J dalton ly100,or less,,
_ I certify that in me perf.rnwnce of He work far which Ih s per CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL {- Ili[ costed,I s)ull nor empfc,'any person in any manner so m w
U bc,.nm,Vpc,t 1.Zhu Walken'Conspensu0on Laws of C'aiI'umia
Q. Uan APPIIEam ALTER OR ADD TO MECH. 5.00 BUILDING SL 11 SU
N NO110E TO APPLICAN"C If.alter makin6 this Certifi.....f Fn-
F- 2 elliptic,,youshould become su bjm I Ihr Workrn'Con,Pnuanion APPLIANCE 5.00 PLAN CHECK
provision, of the "bur Code, you lout forthwithm
L. ply wilh (19-j
U such provisions.,this permit 1flat[be denncd rm'okrd. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00 FEE a Q
CONSTRUCTION LIiNUING AGENCY AIR HANDLING UNITIOVER I0,000C.F.M.) 6.00 SEISMIC FEE S
I hereby affirm that there i, a c.n,lructi... [coding agency lir EXHAUST HOOD IWITH DUCT) 5.00
the perlunnmtce of the work In,which this prnnil is issued ISec. MICROFILM
3097,Cis C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
I certify[bat I have read this applicalion and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply will,all city and county PLUMBING
ordinances and state laws relating hl building 4omb'uclion, end BOILER-OOMP(3 H.P.or 100,000 B.T.U.) 6.00
U hereby enthowd oPtnt,f r by , this city to enter upon tlly BOILER-COMP [Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-menthroo propeHy forin,peC this
purposes.
(We) agree to save, indenusily and keep hunnless Ihr Cily'ul MISC.- REFER TO ORD.
Cupertino again,, liabilities,pulgmmu6, 4.11 and espcnsn whidl CONT.TAX
may in any way accrue against said City ill consequence of file PERMIT ISSUANCE 10.00
/ •mn •u Ills pcnhtl MECH.CONT, LIC.NO. MECH.
/\ 1 ��' TOTAL TOTAL 7 �I
Signature of Applicant/('ont ID Dul
OFFICE COPY