6719 (2) APPLICANTTO FILL IN-IN,FORMATION WITHIN RED LINES -'USE BALLPOINT PEN'ONLY '
•BUILDING PRO ECTIDENTIFICATIO 'PERMIT NUMBER
APPLICATION &PERMIT
X NIIILnI NG 71 (�'Jr
f' x_-
ADDRESS
c^ . D - �.1 1 V
In . E.W. BUILDING-ELECTRICAL-PLUMBING=MECHANICAL "
0 R'S `•x - - - - �- - - - PLAN CHECK VALIDATION
NAME 'Q t OTY. ELECTRIC PERMIT FEE "
•' ^ kf ''VLU VA PHONE'. -
} NAMEHAcroms UTLETS:SWITCHES-RECEP 5.00/1.00
S �� IJ� - LIC ND.• .UAL LIGHTING FIXTURES x5.00/1.00
CONTRACTOR'S
ADDDDREESS/ R r,`ki e-)Or �• f' 1: ��( c' APPLIANCES.:RESIDENTIAL 4.00
CAOVI vHON�7dv1{'�:,6144-W PANELS OATS OF APPLICATION -
ARCHITECT PLAN CHECK FEE P.C.NO.
OR - SIGNS 6.00 '
ENGINEER - -
'uC.No. SIGNS TRANS. 3.00
ADDRESS ARCH.OENG. - • SPECIAL CIRCUIT 5.00 - PERMIT VALIDATION
ZIP, EMP.METER OR POLE SINS. 15.00 - PAID
APPLICANT'S
` ADORESs !" I MOTORS SEE FEE SCH kvy
SERVICE CH 1000J /1(/9aFoo LICP-NSED CON TRAGI ORS DECLARA I'IONf� (/ny[Q
¢ w 1 hereby all irm that] Um licensed under provisinna of Chupter9 - - fj.r1 � RX QT lr1Rd]firlllmo
y a y (co ock,ccmg with Section 7000)of Division 3 of the Business anll - �'r'', •t ELECT.DANI ATE
F H z Nofcssimts Co do d t nse is in lull l' }• J BLDG. .ELECT. ' PLG. MECH.
C, °m- License C ass Lic.Numbe-u 1. � EI • , E 0
° z Dam_�O �t2�P Contractor Of Cup .
V ertino
¢ ¢.Wa OWNER-BUILDER DECLARATION GILT - - BUILDING PERMIT
a ,D- MISC.- REFER TO ORD INFORMATION
w ; I hereby-a hunk that I sen exempt from the Contractor's License
_ VALUATION '$/FT.
LL°j Law for the following (Sec.7031.5,Business and Professions '6.00
r - f. PERMIT ISSUANCE
Coprove,y city or county which Structure permit totsi suanc,also
¢ ¢ ¢ improve,demolish,or repair any Smit to Ii e a sign its issuance,also ELEC.CONTR. LIC.NO. ELEC.
° ¢ requires thedp roman for such permit to f fta signed actor's i that - TOTAL /
X m LL he is licensed pursuant to the provisions of the Contractor's License _ PERMIT-TO
H z,i
Law(Chapter 9(commencingwithSection 7000)ofDivision3oftire
4 o Business and Proh room Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ .m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
; _ by any applicant for a permit subjects the applicant to u civil penalty ALTER-DRAIN (EA.) 4.00
'
of not mom than five hundred dollars(5500).):
❑ 1,as owner of the Property,or my employeeswith wages ax SACK FLOW PROTECT:DEVICE 2.00
their sole Compensation,will Jo 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.'4.00 '
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve
-
. mems dre notintcndcd or offered for sale.If,'Imwcver,the building GAS-EA.SVSTEM-I1NC.40UTLETS 4.00
• or improvement is sold within Out,year of Completion,the owner, GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have[he burden of proving that he did not build or im-
proveforpurpose ol'salt.). INDUSTRIAL WASTE INTER. - 20.00 RES IND CON PB Other
❑ I,as owner of the property,am exclusively contracting with - ❑ ❑ ❑ ❑ ❑
licensed contractors to construct lire project(See.'7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ' 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 IEA.)' 1,00
contracts for such projccts,with a controclo".,)licensed pursoant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. r PARCELNO.
- C1 A am exempt under Sec. ,B.&P.C.for this
reason WATER HEATER WIVENT 4.00
Owner 'Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EOUIP. 4.00
1 hemby affirm that I have a certificate ofoomant to self-insure,
or a Certificate of Workers'Compensationns
Iurance,Irr a certified ZONING ENG.SITE N0.
copy thereof(Ser.3800,Lab.C.).
Policy No. Cmnpany
O'' ❑ Certified copy is hereby furnished.', •r: "' ' '' FIRE SHRINK ENERGY T$4
1 Z_ 2 ❑ Certified Copy is filed with the City inspection division. MISC.- REFER TO ORD.Applicant Y❑ N Y O* .,N❑
~ rn PERMIT ISSUANCE 6.00
- CT:R'I'IFICCOMOI°SATION INSFROM WORKIi RS' FLOOD ZONE A.LU.C.
W COMPIiNSATION INSURANCIS PLG.CONTR. LIC.NO. PLG. .
•
CL Cl r CL Cl ('Phis section deal oat [,a completed if the permit is for one TOTAL Y'❑ N❑ V E] N❑
hundred dollars IS 100)nr IessJ - -
U O 1 Celt it that In the performance of the work for which this per. QTY MECHANICAL PERMIT FEE FEE SUMMARY
W H mit is issued,I s all'not emplOY any pt in any manner so as to
O W beer c} t the Workers Compc a sof California.
IS. Lane
NO' .Y41pp1icant ALTER OR ADD TO MECH. 4.00 BUILDING m �
} w Ol'ICP IO 'PI-ICAN'I': If„Ufla ma ing Clic .x- - -
F Z creptinn,you s Could become suhjea to Clic Workers'Compenwtian APPLIANCE - 4.00 PLAN CHECK /
provisions of the Iabor'Code, you must forthwith comply wish (O
U such provisions or this permit Shull be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.11A) 3.00 FEE "
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IQOOOGEM.) 5.00 SEISMIC FEE Iro
:1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00 '
•
the performance of the warts for which this permit is issued(Sec. MICROFILM
3097,Civ.C.1. HEATING UNIT(TO 100,000 B.T.U:) 4.00
Lender's Name EATING UNIT(OVER 100,000 B.T.U.)7.50
' Lender's AJdrns HN
- - ELECTRIC � -
1 certify that I have read this application and state that Lhc above VENTILATION FAN (SINGLE)' 3.00
information is Correct.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating m building construction, and BOILER-COMP 13 H.P.or)00,000 B.T.U.) 4.00
hereby authorize representatives of,this city to enter upon Lire BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL"
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep,harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, cosls�and expenses which :PERMIT ISSUANCE' 3.00 CONST.TAX
may in any way accrue gat t Said City in cdnseruence of the _
gmntin tl permit. y({/ MECH.CONT.' "LIG.NO. MECH. '
0 0 / n�: TOTAL
TOTAL (P -
Signat a of p nt/Contractor - 'U to
t `OFFICE COPY _