6860 (2) APPLICANT TO FILL-IN INFORMATION WITHIN RED LINES- USE,BALUPOINT,PEN ONLY,
BUILDING PROJECT IDENTIFICATION; -• P-EPMrt NUMBER.
BD-La", ;APPLICATION &'PERMIT
anon Ess adO�ILO C7/0(�Q!(�$.rQ K''� Q.�O
i '� - BUILDING-ELECTRICAL-PLUMBING-MECHANICAL - 8
I OWNER'S o PLANCHECK VALIDATION -
/"/A5•,My/E/' SI' 14� - 6TY. ELECTRIC PERMIT FEE' '
. ' 1'74S PHONE _
C^yOyN1TRACT09'S - 'ly OUTLETS,-,SWITCHES-.RECEP 5.00/1.00 1:
i!/N % LIC NOS LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S`O&rf / B R PPLI'ANCES-RESIDENTIAL+ 400
•� PHONE - - PANELS S.00 DATE OF APPLICATION.
FEE
P.C.NO.
M1 PLAN CHECK
ARCHITECT SIGNS - 6,00
• On �
ENGINEER .. stn,�. -3.00 '
LIC'No. SIGNS TRANS.
ARCH,OR ENG. .. _ ,.,5.00 v PERMIT VALIDATION- -
ADDRESS . SPECIAL CIRCUIT;
ZIP EMP.METER OR POLE INS 15.0o.
ADORE.rs /' ' ��p T r/'` MOTORS SEE-FEE SCH
49AW 0 SERVICE CHANGE '• 10.00 F'y
o o LICENSED(76N'1 RAcTORS DECLARATION
avu Ihereby affirmthxt,Iam.hoemosi'under provisions of Chapter9 °ISSUANCE DATE
1° Cn ncncing with Section 7000)of Division3 of the Business and
SLOG. ELECT. PLG. MECH.
wz Profesvians Code nd license is toll force i eOI ❑ - ❑
Lou CI"` Numhcr a
Q z r w Dale CoQ)m meter �__ _
`" - - BUILDING PERMIT
rt w u OWNER-BUILDPR DECLARATION _ _ - INFORMATION M1
a
MISC.- REFER TO ORD
w g u y I heretiy affirm that I am exempt from the Contractor's License • VALUATION $JFT.
u, LL o j Law for the following reason.(See.7031.5,Businessand Professions •PERMIT ISSUANCE 6.00
Code:Any city or county which requim"permit loconslrucl,aler. -
Q Q ¢Q r .
Improve,demolish,Or repair any]truQllrC,prior or its issuan Ce,also ELEC:CONTR." LIC.NO. - ELEC.
i - O u requires the applicant for such permit to lite a signed statement that r x TOTAL ^ PERMIT TO
X
he is licensed pursuant to the provisions of the Contractor',License
H z i
Law(Chapter 9(commencing with Sectio 7000)of Diviswn 3 of the .0 C7
a Business and Professions Code)or that he is exempt therefrom and PTY. ' PLUMBING PERMIT FEE
ecFo the basis for lleullem
ged axepfon.Any violallomof$eetion 7031.$ _ STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER IEA.1 4.00
of not mora lhnn five Imndred dollars(S500f): i
• ❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE '`2.00 .-OCC.GROUP RES.UNITS
III it site compensation,will Jo the work,and.lhe Structure is mol
intended or offered for sale (Sec. 7044, Business end Professions DRAIN LOO OOF,'AREA,CON D. 4.00 e•a
Code:'The Contractor's License Law docs tial apply loan owner of -
properiy+who builds or improves thereon,and who does such work FIXTURES-PER TRAP '• 4.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himsclPor Ihn....It sawn employees;proviJed that such impn,ve- - _
mems.arc not intended or offered foF sate.If.huweveq the hailding GAS-EA.SYSTEM-1:INC
.40UTLETS 4.00
or improvement is sold within one year of,complelion,the owner- GAS-.EA.SYSTEM.OVER 4(EA.) 1.00 HU140ING USE
.builder will have the burden ur in wing that he did not build or im- - - RES IND CON PB Other
prove for purpose of sale,);! INDUSTRIAL WASTE INTER. 20.00
❑'•'l,as owner of the,property,am exclusively contmcling with ❑ . ❑ ❑ ❑ ❑
licensed contractors to'construct the project(Sec.7044,Business LAWN SPRINKLERS-,l INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and profession,CodC.The Contractor's I.Ce s,Law does not apply '
to art-owner of property,who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1:00
contracts fors6ch prolccle with a conlraciood licensed pursuant it,
'I".
I the Contractor's License Law. SEWER-SANITARY-STORM 'EA.20011/8.00 TRACT No. PARCEL NO.
m
❑ .I eexempt under Sec. B.&P.C.for this WATER HEATER W/VENT 4.00
reass�n - !
Owner - 'Date WATER SYSTEM 4.00 r ACC.DATE ACC.FILE NO.
WORKERS'COMPIiNSA'IION DECLARATION - WATER TREATING dallIPL) 4.00 '
I lemby affirm Ilial I have n certificate of consent to self-insure,
or a certificate of Worker Com Pensaliun In�surr, e,or a certrlied ZONING ENG.SITE NO.:
Copy flier 800.Lpb.C.)r I-'�.y/.•,IIDie '... - K 1 1Qa�i .r
1'ohcy Nob& CompeRy _ _ .
❑ Ccftifetl cop is herchy fufplshudr FIRESPRINK ENERGVT-24
Z ZCerl ifely is ed with.t - 't inspection division MISC.- Cj{ O TO ORD: .t
,in
� N CERTIFICATE 017 F-XIMPFION PROM W'OR'ERS: 'PERMIT ISSUANCE 6.00FLOOD ZONE A.L.UC,�
'W >' - .- CO 'fiN SA'FION INSURAN(ai G.CO R. LIC. 0. �-a.,p PLG• n--l�
CLO 1"chis aeti<in-nceJ u,t lee cont petcd if Penn it is.for one �( 1XCPi yy0 TOTAC t�Ory y• V❑ ' NO -'V ❑ N❑
2 hundred dollars 141001 IessJ "
V O ; ' t:•certify that in the pe rmance o e work for which thii per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL
F miis issued.1 shall To eml person in any manner so as to
OO 9 becolue subject to
Worker' 'Pemsation laws of Califoniia.' . 'BUILDING . .
to Date Ap li - I ALTER OR ADD TO MECH. 4.00
} w NO'T'ICE:f0 APPLI r: If,after m ng this Certificate of Ex- -
F'? emotion,you She become subject to Inc arkdr.,'Compensation APPLIANCE - 4.00 PLAN CHECK
provisions of c Labor Code, you must.fo v�hit co ply with -- - FEE --
U 'such provi s or this permmed it shalt be deerevel/ty4./, ,I AIR HANDLING UNIT(TO 10=C.F.M.) .3.00
CONSTRUCTION LENDING f:NCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE
- I herchy uffi I that there is a co miter lending agency for EXHAUST HOOD (WITH DUCT) '2.00 •'
the perlormance 0e work Ibr eh Ihis permit Is Issued fSec. HEATING UNIT(TO 100,000 B.T.U.)' 4.00 :MICROFILM
3097,Civ C.). - -
' I Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7ELECTRIC
.50 's
Lender's AEdress - '
Icerldytl haserea isapplicatiohandstatethallheabor. VENTILATIONFAN (SINGLE).• . 300
Inhinnatl is ort et I car t,comply with all city and county - OOO B.T.U.1 4.00 PLUMBING-
odon ex mod nate laws ION g to.buildmg constriction and ',BOILER-COMPI3 H.P.Dr 100,
I: t' hb ,'an lortte rvp D.sentuli Ls f this city to enter.upon the BOILER-COMP (Over 100000 BTU)SEE FEE SCH, MECHANICAL'
above meat tined property for mspe n purposes '
(We) agree to save indemnifyard ceplharml•ss the City ol MISC.- - REFER TO ORD. -
- Cupertino against liabilities,judgments, costs and expenses,whmh' CONST.TAX
may t any y :Iccme against said City in coisequence sf Ihc. PERMIT ISSUANCE. 300 ,.
gr n or permit.. MECH.CONT. LIC.N0. MECH
" aYjY�! TOTAL TOTAL
SimiatuR%cif Ap 'ant/Contracmf, - ale-
• ° ' - ° OFFICECOPY