5166 (2) 'APF jCANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINS PEN JNLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS r{��/ L 5166
BUILDING ELECTRICAL PLUMBING-MECHANI
NAME C-4.ur ��Z �A. K VALIDATION
6Y 9'(W4/ �VJN WO!-/i00/LJrt OWNER S QTY:`. EI ECTRIC PERMIT+? p FEE'S
WOK. E k,.f'.,Qty. ' ,+tt!d'ae .` s.`.a1S'+.1 &a.
CONTRACTORS
NAM Wa ,y Of/�td y5�6O UTLETS-SWITCHES-RECEP 5.00/1.00
•` /(� a No 7 LIGHTING FIXTURES 5.00/1.00
f,ONTfl ACTOR'S
AOOHEss _ Lr PPLIANCES-RESIDENTIAL 4.00
DATE OF APPLICATION
yS z P�%TeS mi"UI[{{�IHONE 9e5GT/ 1PANELS 5.00
ARCHITECT PLAN CHECK FEE P.C.NO.
OR SIGNS 6.00
ENGINEER
ua No. SIGNS TRANS. 3.00
ADDRESS ENG. PERMkDATE
/
Aaoflass SPECIAL CIRCUIT 5.00
ZIP EMP.METER OR POLE INS. 15.00 wooessrsMOTORS SEE FEE SCH.SERVICE CHANGE 10.00
iF00 LICENSED CONTRACTORS DECLARATION
a u U I hereby affirm that 1 am licensed under provisions of Chapter 9
se<y (commencing wish Section]000)of Division 3 of the Business and ISE PLGMECH.
r m z Professions Co y license u in full fore sn t �' c. .. ❑ ❑
0„, - License Class �I Lie.Number \
Date]? 'e/'7 Contractor
B Il'DINSi;$EPMIT
0 w OWNER-BUILDER DECLARATION - t,f- (11FORMATItIN
;'w I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD ygl.ugnON/
v.o j Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE SIFT.
'^ Code:Any cityor county which requires a permit to construct, 6.00 q�,r
mf
rt Q G improve,demolish,or repair any structure,poor to its issuance.also ELEQCONTR. LIQ NO. ELEC. V
o ac requires the applicant for such permit to file a signed statement that TOTAL
E:
he is licensed pursuant to the provisions of the Contractor's License I PERMIT TO
r z Q Law(Chapter 9(commeneingwith Section 7000)of Division 3 ofthe �" izh Ai�'+F1i/>.i-rl`ia'STd".bre° - `" r� p �/
E 4 0 Business and Professions Code)or that he is exempt therefrom and QTY: PLUMBINO'PERMI,T - ,�FEE�'
¢r the basis for the alleged exemption.Any violation of5ection 7031.5 ' 1
LTi' r NOW
'?{'-..fit-.. ..gip. ,, � ',j-'7_-. STORIES TYPE CONSTR.
N_ by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN (EA.) 4,DD
afoot more than five hundred dollars($500).): A /J?I'l
❑ 1,as owner at the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 11�o1CCL/.IGR/OUP RES.UNITS
their sole compensation,will(S the work,and the structure is not OCC.
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 NA-I
Code:The Contractor's License Law does not apply to an owner of f
Property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 4.00 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
meats are not intended or offered for Sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is Sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1,00 BUILDING USE
builder will have the burden of proving that he did not build or im-
pro1. purposeas owner of the.)' h INDUSTRIAL WASTE INTER. 20.00 E5 IN❑D C❑ON OEl ther
❑ d as owner of the property,he exclusively contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSE5SOHS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to anowner of properly who builds improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.0
contracts for such projects with a conirtr acSorts)licensed pursuant to
the Co
the Contractor's License law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec...B.&P.C.for this
reasonWATER HEATER W/VENT 4.00
Owner Dale WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy
lico 3 Copb.Y.1.yNm �9%✓ �(��1�
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY TN
z 2 Certified py is filed Itll the city inspection division. I❑ N , V ❑ N❑
O A Phcanl ,1�/,1_ E-Y(y MISC.- REFER TOORD.
D- T CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOOZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d O (This section need not be completed if the Y❑ N❑ V❑ NEI
Ili
p Parrott rs for one TOTAL
2 hundred dollars IS 100)or less.) - t
L) O I certify that in the performance of the work far whish Ihre p Cin;y kYt, y v'1 'w"' �-1' } 't5 'r sr"gF'''�{R s C 5{§3 FEE SUMMARY"
)- mil is issued,I shall not em to an QTY "� .ti.MECHANICAL.PERMITre""w,+1.k.° x,FEE,, 3..t...,. . kwx
LL P 5' Y Person in uny manner so as to {u yxs Ly ya - -
0 W become subject to the Workers'Compensal ion laws of California. u �'"'"+°~E.^,J"{ , '+ - 's.. tz `� I -lig^3 a4`+0.
to Date Applicant ALTER OR ADD TO MECH. 4,00 BUILDING ') `�I
} Z NOTICE TO APPLICANT: If,after making-this Certificate of Ez-
F _ emotion,you should become subject to the Workers'CGmpenvlion APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code,you must forthwith comply with 'FEE
U such Provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.NL) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE rS�
I hereby affirm that 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
f - Lender's Name
Lender's Address HEATING UNIT(OVER 100,00013.T.U.17.50 ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is cemeet.1 agree to comply with all city and county PLUMBING
ordinances.and state laws relating to building construction,and BOILER-COMP 13 H.P.Or 100,000 B.T.U.) 4.00
hereby authorize repreaentalives of this city to enter upon the BOILER-COMP(Over 100.000 BTU)B
above-mentioned property for inspection purposes. EE FEE SCH. MECHANICAL
(We) agree to Save,.indemnify and keep harmless the City of MISC.- REFER TOORD.
i;� ; Cupertino against liabilities,judgments,costs and expenses whichCONST.TAX -
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
grarlti Fild �permit.
�� � MECH.CONT. LIC.NO. MECH. ,
� TOTAL iprs��
bigiffalure of Apphcant/Con[mctor O
- ., OFFICE COPY -