15542 (4) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
BUIL DING PROJECT IDENTIFICATION PERMITNUMBER .
Ron DING APPLICATION & PERMIT 15542
BUILDING—ELECTRICAL—PLUMBING-MECHANICAL
}yt, OWNER'S PLAN CHECK VALIDATION
;,gAw'at t NAME. CITY, ELECTRIC PERMIT FEE
PHONE
CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00
_y j NAME '
X "C.No Z LIGHTING FIXTURES 10.00/1.00 . ,
CONTRACTORS - APPLIANCES-RESIDENTIAL 4.00
AD/ODDRESS
•a PANELS 10,00 DATE OF APPLICATION
ARCHITECTPLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC,NO. SIGNS TRANS. 3.00
ADDRESS ErvcSPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLIANTS MOTORS SEETEE SCH.
ADDRESS
SERVICE CHANGE -20.00
o w 0 LICENSED CONTRACTORS DECLARATION
a U
u I hereby affirin.tlml 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
wN Professions Co A 'license is in full to f BLOC, ELECT: PLG. MECH,
Is
z m D Licenu CI' Lia Number L' ❑ _
,A r
Uutc Con tracwr
a m f -I BUILDING PERMIT
R O 6 u OWNHR-BUILDER DE
X g LL H I hereby affirm That I am exempt from the Contmc s License MISC.— REFER TO ORD INFORMATION
a- 0¢ Law for the followbn g reason.(Sec.7031.5,Businessand Professions VALUATION $/FT-
� Cade:Any city or taunt which re PERMIT ISSUANCE 10.00
y structure,
permit oconslnmce,al r,
¢ a,¢ 0 improve,demolish,nr repair any strut lure,prior signed
Els issuance,also ELEC.CONTR. LIC.NO. ELEC.
O¢ requires isic the applicant for such permit to file a signed statement Ase . TOTAL �;PERMI O
o hat
w $ he is licensed pursuant to the provisions of the Contractor's License ,eyTl
r z i Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Q Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
a.= $ the basis for(he alleged exemption.Any violation of Section malty STORIES TYPE CONSTR.
a ; � by any applicant fora permit Sdollars $500).applicant toacivil penally ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).1: '
Cl 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
r Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP '5.00 SO.FT,FLOOR AREA TOTALACREAGE
himself re through his own employees,Provided that such improve-
mmats are through
Emended or nem employees,
sale.If,ed that such
he building GAS-EA.SYSTEM-1 INC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA,SYSTEM-OVER 41EA.) 2.00
builder will have the burden of proving that he did not build or ins- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES IND CON PR Omer
-CI I,as owner of the property,ran exclusi . .
vely contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Set.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The 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 costtructons)licmtSM pursuanLto
the Contractor's License Law. SEWER-SAN ITARV-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. B.SP.G.for this WATER HEATER W/VENT 6.00
mason
M Owner Late WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
_1\ I hemhy offina lfmt I havu a Certificate of consent to self-ins ufe,
1`( or a c I ficule of Workers'Compensall Insurance,ora certified ZONING ENG.SITE NO.
Oc t r�,(S�Q�}19B�P�N C.).
vP 1 ipj-TXC6m(�:Iriy 4
O 0 �{MIctl copy is hcrehy furnished. 6PRINK , ENERGY T-24z Z •ITCertified co f rfll the city inspection divisiim, MISC.- REFER TO ORD.
O Applicant OleY❑ N❑ Y ❑ N❑
~ PERMIT'ISSUANCE
• N C1171''11 1C l', •IiX' ION FROM WOR KIiRS' p •ssp pLOOD ZONE A.L.u.C.
dQ COMPEN ION PON PLG.CONTR. LIC.NO. TPLff
OTAL CUPe -Y❑ N❑ Y❑ N❑
(This ualidn nceJn he count
if the permit is for one
D Z hundred dollufs($100)or Iew.l lillif
U 0 1 certify that in the performance of the work to,which this pep CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as In
O W become subject to the Workers'Compensation Laws of CRlifomia. - -
a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>- (n NOTICE'I'O APPLICANT: 11,after making this Certificate of Ex-
♦— Z enlption,you should become subject to the Workers'Compensation APPLIANCE PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO I0=C.F.M.) 4.00
CONSTRUCTION LENDINGAGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit I,issued(Sue. - MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T
Lender's Name HEATI NG UN IT 100,000 B. ,U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information n correct I agree to comply with all city and county BOILER-COMP(3 H.P.Dr 100,000 B.T.U.) 6.00 PLUMBING
ordinances and stole laws relating to building <Onatrutllom unJ
hereby authorize representatives of this city I. enter upon the BOILER-COMP (Over 100,000 BTUI SEE FEE$CH. MECHANICAL
above-mentioned property for inspection part,
(WC) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities„judgments, costs :rod�hi ,....es which PERMIT ISSUANCE 10.00 �- CONST.TAX '
may in any way accrue against s 'd�City in comse9l ACC of ne
ranting of c �y MECH.CONT. LIC.NO. MECH.
a /"/ / TDTAL ; TOTAL
pignaOf tur t an Co Ctor e 2�
OFFICE COPY