13285 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
DO LOINS APPLICATION & PERMIT
AOOflEss 3 2 8 5
BUILDING - ELECTRICAL-PLUMBING -MECHANICAL J
ER's /✓ ✓ PLAN CHECK VALIDATION
T NAME OTV. .ELECTRIC PERMIT FEE
cont CTOR'S
nA OUTLETS-SWITCHES-RECEP 10.00/1.00 ly/'/
LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
flE"
PHONE PANELS 10.00 DATE OF APPLICATION
'
At TECT PLAN CHECK FEE P.C.N0.
On ,/ yy PANELS (OVER 200 AMP) 20.00
E .1 ? / uo' / sL7 � SIGNS TRANS. 3.00
ADDRESS Enc' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
AP eSss Ts MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
2
0
wCON .1 r` .•�'•
Hoo LICENSIiU 'f ItAC'PClltS UECLA RATION
a u W I hereby a]I nn Owl I an+licensed under poo sions of Chapter 9 ISSUANCE DATE
N a a (e.on eru n,with Section 7000)of Divi,iun 3 of the Resines and Li IB )(;' Ilii' PLO. MECH,
r o i Poodessimss Code lyl�Oy license is in full to I
Z, 0 L o Licansc Clay _(� _Lie Nuru be 3 � .r ❑ ❑
L f w Dale _ Conlnct
�l- t�t3 ,�. :W
a m P � � BUILDING PERMIT
¢ ¢ w OWNER-B UILUIiR DG('LARA )N INFORMATION
w ;d n 1 hereby affirm Thal I and exempt Roll the Clouse ores Ll.ns.. MISC.- REFER TO ORD
t. 004 Lawfor the bllowing mason.ISec.7031.9,It...inm.. Prulmsion, PERMIT ISSUANCE 10.00 '.'I' VALUATION S/FT.
,A> w Code:Any city or rnun ly which rcquil Is a felon' ocuna'Ins1,:JIrI, i'=
¢ ¢ 4 improve,destolid',or repair airy sit act arc,prior to its i,wxnre,aha FLOC.CONTR. LIC.NO. [LEC. 'r -
a LL requires the applicant for such permit to Im
de a signed stateent Uwl TOTAL 1 1
A w tic is licensed pursuant to the provisions of the Contractor's Liceme PERMIT TO
r i I,uw(Chaplcr'1lmtmm�ming with Suction 70001 oI Division)ni the = _ -
F i c Business and Profession,Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE -
¢ I_$ the basis for lire allege)cxnoplion.Ali, iolatimr of Section 7031.$ STORIES •~ 'TYPE CONSTR.
a ; byanynore tient Cut apjidredsbjuc',(S50u plicalu mucivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not mom Ilan five hundred dollen f 59DU).1:
❑ I,as owner of the property,or my critycc,with wages:" BACK FLOW PROTECT. DEVICE 4.00
their sole Cuntpenaation,will Jo lire wmkl and the,trucWro n u0I OCC.GROUP RES.UNITS
intended or uflered $or aide (Sec 7044, 9usmom s and P+ufealuro DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does nut apply to an owner of
property who builds or iwprovca Ihercon,and who it....such ward: F IXTUR ES-PER TRAP 5.00 SO,FT.FLOOR AHEA TOTAL ACREAGE
himself or through his own employee,,prodded that well hoporc imGAS-EA.SYSTEM-11NC.40UTLETS 6.00
`• men"are net intended Or Offered for vale.If,huwcveq lire building
or provement is sold within one year of cunipdetlon,the owner GAS. EASYSTEM-OVER 4 (EA.) 200 BUILDING USE
will have the burden of proving that he did not build m iu+ . . . RES IND CON PB Omer
prove for purpose ,I the... INDUSTRIAL WASTE INTER. 30.00 � 0 0 ❑ O
❑ 1,as owner of the Pmpurry',sem ex.hsivay Cont raring with
licensed contractors to construct the project(See. 7044,BuHin... LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and PoWe"fons Code Ihlu ContrmlulS Liauuw Law does not apply
to an owner of pnq+cny wlu builds o1 iuplos Cs thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00 _
Contracts for such projec"with a contranor(o licensed punuam to SEWER-SANITARY-STORM EA.200''110.00
the Contractor',License Law. TRACT NO. PARCEL NO.
0 I amexompt under See.-,B.&P.C.'..this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
/7) r/y7�- ACC.DATE ACC.FILE NO.
(//(P/�I"Y%v6�.Yfl'uN'Uet'Ln1<nTION WATER TREATING EQUIP. 5.00 �
I hereby alfinn Ilial I hate a e,U lioum oI e+ sent to s11 leu IC' ZONING
or a rutiGrxm of Workers'Comp,,1 aI n IIs liflu:l ENG.SITE NO.
COPY thereof(S,,.3800,Lvb,C.l.
Policy No. Company'-
O ❑ CertiHad 't Py is hereby fumi,hod FIRE SPRINK ENERGY T]4
Z Z 0 Certllf�y_ l,y i. fled 'th" 'i m,pe' ' I or,mon.
O Anplica+l'/j-Ae /JJ�J'h'L�-�U MISC.- REFER TO ORD. Y � N� v ❑ N�
~ w PERMIT ISSUANCE 10.00
La CEBI'II9LCONi OPSA]ION IOM1'PRDNIWOIilaiBs' FLOOD ZONE A.L.u.C.
W 0 CCIMI'IiN5A1'ION IM1'SUItt NCI: PLG.COM'R. LIC.NO, PLG. YE] N Y [D N�
Z ndre senior f,10 nt be callplcn•J il' Ilia Penni' is Im aur TOTAL
hundred dollen lS IOUI aI Icss-1
U 0 1 eenil'y if,,, iu Ih, perfunnanee ul the work lar whrh this per- FEE SUMMARY
y y peon in any n+onner so a,to DTV. MECHANICAL PERMIT FEE
0 U mit is issued, I shall a ul cruplo C an ,
Q w become su Dject to the Workrrs'Cmnponsmiml Laws nl'Culil'umix.
n Dale API'lleanl ALTER OR ADD TO MECH. 5.00 BUILDING
} in NOTICE TO AI111LICANI If,atm,laking thi,Co Hifira'e of i.e-
F 2 eruption,you slluuld beeonte subject to the Worken'CompersAiun APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must I...havith eO'n Ply with FEE
U such provisions or this permit shall be docnled rn»krJ. AIR HANDLING UNIT(TO 10,000C.F.NL) 4.00
CONSTRUCT ION LBNDINC AGENCY AIR HANDLING UNIT(OVER IO,000C.F.M.) 6.00 SEISMIC FEE
I hereby affirm 1W' there is a construction lending agency lin EXHAUST HOOD (WITH DUCT) 5.00
the perlonnan" it thew for whicb 'hi.+...Ilii, ie lauwl. (Ste MICROFILM
3097,Civ.C.), HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Nano_ is'F
Lender's Address H EATING UN IT IOV ER 100,000 B.T.U.)9.50 ELECTRIC
I omify that I has,r.d this appliry nun ani stat,that the uboso VENTILATION FAN (SINGLE) 4.00
infom
ration o caned. I 'agnc to rump), ni111 all it, and rounDPLUMBING
--. Ordinances and state laws relating BI building conatnmtion, Trill BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00
hereby authorize n'presC•nlafives OI (lis Citylu rn let upon file BOILER-COMP loser 100,000BTO)SEE FEESCH. MECHANICAL
above-mentioned pnlpeny for impend on pluposm,
(Wa) agree to ..... hic,, nd, and keep Imin Jess the (City oI MISC. - REFER TO ORD.
Cupertino aga�Ihs,"u neat . .nu, and cePrnaa.which PERMIT ISSUANCE 10.00CONST.TAX
i uly1h ns+/alI 1 ' in ramc.luence of theranttngu 11 / WCH.CONT. LIC NO. MECH.
. � ��_ TOTAL TOTAL ( I-
$ignaturc of o,is D te- - - l�
P oioFICE COPY