6919 (2) APPLICANT TO FILL IN INFORMATION WITHIN-RED. LINES - USE BALL POINT PEN ONLY
.. BUI L61 NG PROJECT I DENTI FICATION ' 1 - PERMIT NUMBER
4. BUILDING APPLICATION'& PERMIT ^^ '.
Ao-L�Z�-� �. L ( _SS
G�^�ry_„ 8 BUILDING-ELECTRICAL-PLUMBING -MECHANICAL b y
OWNER'S 7_.1�ILP�j. 'r.w. G - _ _ _ - '''
PLAN CHECK VALIDATION
NAME •: OTY: ELECTRIC PERMIT FEE
#iP Stix P� S)Ya4i z3
CONTRACTORS
NAME ^,' UT LEIS
-SW'TC
HES-RECEP 5.00/1.00
� s •yass�ELL uc.Na � I LIGHTING F XTURES 5.00/1.00 •r -
GONfHACTOR'S
ADDnEs /, j�� PPLIANCES-RESIDENTIAL 4.00 ^
gook Jor.lt< sr ' l-t 1� t `
PHON S'✓• _ PANELS. 5.00 DATE OF APPLICATION
ARCHITECT
OR SIGNS - 6.00 CPLAN CHECK FEE P. .NO.
-
ENGINEER
i4C.No. SIGNS TRANS. _ 3.00ARCH.OR
'
ADDRESS ENG. r SPECIALCIRCUIT - 5,00 PERMIT VALI DATION
' ZIP TEMP.METER OR POLE INS. - 15.00' S Q/�-'
APPLICANT'S
ADDRESS V
s MOTORS' SEE FEE SCH. fN(f.✓
. •. , ` - SERVICE CHANGE 10.00 �//�(
,F o O LICENSED CONTRACTORS DECLARATION PAID
a �u I herehy affirm that I am licensed underprrvisionsof Chapter9 = "'
2 i ISSUANCE DATE
y a rn (commencing witl,Sec ion 7000)of Divisiom3 of the FIR.Wess and 1 1
(� BLDG. ELECT. PLG. MECH.
F w z Professions C and my license is in full for - t✓ G - ❑ ❑ ❑
o License C TSS Lia NumM1er
L
Oz V gJyy(
( w=w Uslc�fq,I_�1 Colt/moor-�� - -
.ef,y �'� '
,¢ ¢ w a OwNMi-13UILUIiR DECLARATION BUILDING PERMIT
a °n.o MISC- •' REFERTO ORD INFORMATION
w 3 y I hereby infirm that I am exempt from the Contructots License
u O¢ Law li,r We following reason.(Sec.7031.5,Businessand Professions' - - '•.VALUATION $/FT. .
H - U PERMIT ISSUANCE 6.00 W, �"
cowig Code: e,ymolishcounty which structurep riort oconinance,also
,
u, ¢ a O improve,demolish}or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ECEC. -
o¢. requires the applicant for such permit to file a signed statement that TOTAL
c al he.is licensed pursuant to the provisions of the Contractor's License - PERMITTO -�•
Hzi
Law(Chapter 9(commencing with Section 7000)of Division 3 of the `1��/-Q
4 o Business and Professions Code)or that lie is exempt therefrom and QTY. PLUMBING PERMIT _ FEE ss
ec I-$ the basis for the alleged exemption.Any violation of Section 7031.$to s STORIES TYPE CONSTR.
by any applicant for a permitsubjects the applicant to a civil penalty '
of not more than five hundred dollars($500).) ALTER-DRAIN&VENT-WATER JEA.) 4.00:
❑ I,as owner of the properly,or my employees with wages as, BACK FLOW PROTECT:'DEVICE .2.00 OCC.GROUP RES.UNITS
their sole mm pensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 4.00 -
' Code:'Pile Coulractos's Licume Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.TT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- -
meatsareTal intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 4.00 ,
or improvement is sold within one year oLcumpleticur tire owner,
builder will have the burden of proving first he did not build or im- GAS-EA:.SYSTEM-OVER.4 (EA.)• 1.00 BUILDING USE
prove for purposeof.1the.j. - INDUSTRIAL WASTE INTER. 20.00 RES O r❑ ❑N ❑ ❑
❑ I,as owner of the property,wn exclusively contracting with `
licenscd contractors to construct the project(See. 7044,Business LAWN'SPR IN KLERS:1 INC 5 V.B. 5.00 ASSESSORS PARCEL No.
and Pm Nusiom 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
connotes Iia Such peojeels with u eoNractorlsl heart]putsuu ll to - -
tireContractor'sLieemeLaw. _ SEWER-SANITARY-STORM EA.200ft/8.00 - TRACT NO. PARCEL NO.
❑ turn exempt under Scc. ,D,&I'.C.for this
rl'aSOn WATER HEATER W/VENT 4.00
Owner DateWATER SYSTEM 4.00 ACC.GATE ACC.FILE NO.
WORKF,RS'COMPENSATION DECLARATION WATER TREATINGEQUIP. 4.00
1 hereby thrills that I have a certificate ofconsent to self-insure, "
or a certificate of Workers Compensation 11�s mace,nr a eprlH'•d ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.CJ.�.� 'f( yl f.. .1
Policy No. • Conr any
" 0 ❑' Certified o yish• •b furnished - FIRESPRINK " ENERGY T-24
Z O CerUf ted s I Willi tine city'iovection division.
.F _ Appccant_ MISC.- REFER TO ORD. Y sl N 0 Y ❑ N[
CER fl ltlC\\A'I F OF EXEMP'T'ION FROM WORKERS' PERMIT ISSUANCE 6.00 r FLOOD ZONE AL.U.C.
W - (70413NSAT10N INSURANCE, PLG.CONTR.' LIC.NO.' PLG.. -
d C3' '(This-wetion need not be completed if the permitislie one, TOTAL .w Yo _NC Y❑ NO
� Z It,ndied dollars IS 100)or less.)
0 O 1 certify that in the performance of tile work far which this per DTV MECHANICAL PERMIT FEE FEE SUMMARY
0 F mid is issued,I shall not employ any person in any manner or as to
U become subject to the Workerx'Cnmpeneatian Laws of Colilornia.
a Dam APPlicam ALTER OR ADD TO MECH. q,pp BUILDING '
} w NOl'ICE'1'0 APP[,ICAN'l': IL after making this Certificate of E.-
2 emp0on,you should become Subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
Provisions of the labor Code, you must forthwith comply with U FEE such provisions or tins permit shall be decreed revoked' AIR HANDLING UNIT(TO 10=C.F.M.) • 3.00
CONS'IRUCHON LENDING AGENCY AIR HANDLING UNIT(OVER 10=12,E1,01.) 5.00SEISMIC FEE
I hereby affirm (fiat there is a construction lending agency for EXHAUST.HOOD(WITH DUCT) 2.00
the performance of the work for'which'.this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000B.T.U'.)7.50
Lender's Address ELECTRIC
I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00 ,
• information is correct. 1 agree to comply withall city and county PLUMBING
ordinances and state'laws.rela(inggto building`emnstruction, and BOILER-COMPO H.P.or 100,000B.T.U.) 4.00
hereby authoriae'representatives oCthis-city to enter upon the mBOILER-COMP(Ov,100,000BTU)SEEFEESCH. - MECHANICAL
above- entioned property for inspection purposes,
'(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgnents,•custs and expenses which CONST.TAX
may 3" any w y aceto a I d City,I. c rmqu ce i the PERMIT ISSUANCE 3.00
gra ing of t nail. ' MECH.CONT._ LIC.NO: MECH.
1148 o \ 5 orgL TOTAL
Srgnatureof Appl' an(/Contractor Date - -
OFFICE COPY ',