8156 (4) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUIf DING PROJECT IDENTIFICATION PERMIT NUMBER
C0ICINc. APPLICATION & PERMIT I
56
AOOFf 55
U .� sZ Sk\J�( 10o J e- BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
11 OWN y
NAMt��V6RMV/� " 2!' ��_b3 QTY. ELECTRIC PERMIT FEE P CHECK VALIDATION
CLS.IL.L LV7'`} I
ONE
NTflALTOB'S
/ NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
Cp/.ij; L,c No. 3 4.01- LIGHTING FIXTURES 10.00/1.00
CONTRACTOR sO/-tea N -L ��- -RESIDENTIAL 4.00
ADDRESS /�TY'�I q v�"�
V\' J0&L- PHONE �,92��Q Y/ PANELS 10.00 DATE OF APPLICATION
ORCNITEC�A�M« N R�ry (��IGN PANELS (OVER 200 AMPI 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER �/' Y'E�
LIC.NO. l 19 SIGNS TRANS. 3.00
ARCH.OR
AOGRESS ENG Sj }00 SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
.�5 f N A41wta r /1
S a- 'Ja SL zIPlvla TEMP.METER OR POLE INS. 20.00
APPLICANTSR
ADDRESS
/L MOTORS SEE FEE SCH.
SERVICE CHANGE 2000.
O o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 p
a u I hereby affirm that I am licensed under provisions of Chapler9
y 2 w ISSUANCE DATE
Q N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r N i Professions Code�,3Id my license ism full fore a n ut`
o i h W License C�e,��f.7,_�Lic.Number • '�"'7-- j '® ❑ 11
m Dale J'ftYS±=j( / Contractor I f 0.1Y
y I
¢ � w a OWNIi R-BUILDER DECLARATION BUILDING TION O MISC. REFER TO ORD
K ;LL N I hereby affirm That I am exempt from the Contractor's License
u O Q Law for the following reason.(Sec.7031.5,Rosiness and Professions VALUATION S/FT.
- PERMIT ISSUANCE 10.00
n m Code:Any my or county which reqstructure,
permit toconsuance,lter,also no
Q Q Q improve,den10I1SB,or repair any SINLIIIIe,pr1Ur 101151S5llarlCl,aISO ELEG CONTR. LIC.NO.
DLL requires the applicant]or such permit to file a signed Statement that TOTAL PERMIT TO
w w$ he is licensed pursuant to the provisions of the Contractor's License
w, 10 Law(Chapter 9(commencing with Section 7000)offhvision 3 ofthe
i O Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
the basis for the alleged exanption.Any violation of Section 7031.5
A by any applicant for a output subjects the applicant to a civil penally STOTYPE R.
CONS
of not more than five hundred dollars($500y): ALTER-DRAIN&VENT-WATER (EA.) 5.00 az, CO
O 1,as owner of the property,or my employees with wages as BACK FLOW PROTECTDEVICE 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
Code:The Contmetor'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 /. p0 O
himself re through his own employees,provided that such improve- SOFLOOR AREA TOTAL ACREAGE
CP FT.t3
mems are not intended or offered for sale.If,however,the building GAS-EA.SVSTEM-l1NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of saleJ' INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB 011ie,
as
❑ I, Owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec.7044,BusinessLAWN SPRINKLERS1 INC 5 V.B. 6.00
and Professions Code:The Contractor's License Law does not apply - gp- p
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 6ASSESSORS PARCELNO.
9_� ...Q3 rL
contracts far such projects with a contractor(s)licensed pursuant to 3
the Contractor's License Law. SEWER-SAN ITARV-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner Uatc WATER SYSTEM 5.00
ACC.GATE ACG FILE N0.
\/ WORKI!RS'COMPIiNSAT10N DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofemsent io self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy tlmr4010IN
oab.C. n
policy Nopant $n4,fNC_t-j"
LL
O ❑ Certreby sheJ. FIRE SPRINK ENERGY TZ ❑ CerIle h the Uy inspection division. 24Applicant MISC.- REFER TO ORD.CEIiXEMP ONOM WSO 3 R PERMIT ISSUANCE 1000Y NY No
FLOODZONE A.L.U.C.
LU SATION INSURANCE- PLG.CONTR.CLZ (This sbe completed if the permit is for one TOTAL VE] NC] V N�
U O hundred dollars f S 100)orIv,,f
I certify that in the performance of the work for which this per- QTY. FEE SUMMARY
LL U mit is issued,I Shall not employ any person in any manner so m to MECHANICAL PERMIT FEE
become subject to the Workers'Compensation Laws of California. W
O y
Date.Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE TO APPLICANT: If after making this Certificate of E.-
F-. ? emotion,you should become subject to the Workeri Compeneal ion APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I04010CF.M.) 6.00 SEISMIC FEE S'O
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 is issued(Sec.
3097,CieC.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name GL-G�41/hw-' ny ilifg-
Lender'sAddress HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
. ordinances n correct I agree el to comply with all c city and county PLUMBING
Ordinances and a re laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00
hereby authorize representatives usty moves of this city to enter upon tire
above-mentioned pro erly for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to c ndemnand keep harmless the City of MISC.- REFER TO ORD.
Cupertino agm i fes,it Tents, costs and expenses which
may in any w ago' s said City in consequence of the PERMIT ISSUANCE 10.00 CONST.TAX
granting Uf tl � MECH.CONT. LIC.NO. MECH. [�
�' ? � TOTAL TOTAL p d t'`�
Signature ofA pli /Contractor ate K
OFFICE COPY