13639 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER.
811 DING 2 o ��ENS APPLICATION & PERMIT
AC.vess
�G lLNJD N BUILDING'-ELECTRICAL-PLUMBING-MECHANICAL 13639
"Tbvt1'IAJ
Dy+y Eq9 �i1G UT�f PLAN CHECK VALIDATION
I� 'Q _1lGi`j_ �8 •yJ�•3g33 Qjyj.fes. EL'ECTRIC'PERMIT ,FEE
L,�S1�jZ vHONE Iv1..t y '3' `. ':R"''^A;.�`tR"
CONTRACTORS UTLETS;SW ITCH ES_-R ECEP .,10.00/1.00
NAYS -�•���
SZ VE PO L. f�4• 5L I • L•(d-7fo. LIGHTING FIXTURES � 10.00/1.00
CTRACTO"F I-Er- rl'1'a'I APPLIANCES-RESIDENTIAL 4.00
AOUR ESS
Q9 � F11 LLsbPIE 4+ 7Z Illq PANELS 10.00 DATE OF APPLICATION
/- Aq PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
I OR
IEP
LIck4^eDMINCsCGVuOA1ZGUITEL.T SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDREss
Sbc E'L YN1fN0 q 4QIZZ EMP.METER OR POLE INS. 20.00
Avvuuers
ADDRESS ��[OaJv��yyL II•!'>'>rRIdO.'ll MOTORS SEE FEE SCH. lU//[I_►e-J /(/.a. '^/^_`'. .",
MoN"1GoMF
—428415F 94io,4, SERVICE CHANGE 20.00 �f f
o LICENSED CONTRACTORS DECLARATION
Q I hereby affirm that I am Eanxd under provisions of Chapter 9 ISSUANCE DATE
(Commencing with Section 7000)of Division 3 of the Business and BLD lfQL��7Lf�E'CLT. PLG. MECH:
- z Profession CWe mY Ilcelsse u in full!o ( 1I _❑ ❑I:
S Liana Lia Number 1, -u
i - Date Contractor 1qk LI
1 <>< 'POFD+' _ING�P,ERMIT.
rt ¢ OWNER.BUILDER DECLARATION ?, y� ,QRMATION
Tw 3 I hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD -- ---
VALUATION s't e.VFT.
i rLL Law for the following remos.(Sm-703 1.5,Busineuemd Professions PERMIT ISSUANCE 10.00 <•-'��"%L ����,,.
Code:Any city or County which require apermittoconstruet,alter, «I r
I > ELEC.CONTR. LIC.NO.
¢ 'a¢ unprove,demolish,or repair any structure,prior to its Issuance,also
ELEC.
n x e requires,the applicant for such permit to file a signed statement that TOTAL PER LTM r
La
m A he u liamed pursuant to the provisions of the Contractors License i+rtt•^ s Jam/rltr�
FZi• Uw(chapter 9(Commencin with Section 7000)of Division 3 ofthe ' --e�s4ia
¢F D Bushes and Proleniom Code)or that he is exempt therefrom and OTY:!•a`j '" PLUMBIN,G..r,PyE��R„MIT -fir' FEE -
` the basis for the alleged exemption.Any violation of Section 7031.5 !A”(.S'�91 a` `S� Sf :r!'a'TiSbia'.85AYtr" - �. SLTORIE_S q TYPE CONSTe.-=
byany applicant for a permit subjects the applicant toe Civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00 ��^HL�. j
7.` ofno[mort than five hundred doWn(5500)J: : I SST �:Lf^ -3i�1Kae -7
8 ❑ I,as owner of the property,or my employees withwages as BACK FLOW PROTECT.DEVICE -i ;4 DO OCC.GROUP RES UNITS -e -
thew sale compensation,.will do the work,and the structure u not A..i, 'au-Fe. I
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 5.00
Code:The Contractor's Liana Law doe not apyly to an owner of - ���; i`J,.^!�+•S+' a
r property who builds or improves thereon,and who does such work FIXTURES-PER.TRAP .a,} pi'fP;,600 � Part FLOOR AREA TOTACACREAGE ,•
himself or through his own employes provided that such improve, )rl.�
. - menuare notintendedoroff.md fonaalC If,howeveq the building - GAS-EA.SYSTEM -11NC.40UTLETS -600 h 93�UoSIO,
1°sx. or hnprovement a Paid within ane year of Completion,the owner. t, GAS-EA.SYSTEM OVER 4 IEA I -; 2 00 "L. [B:
builder will have the burden of proving that he did not build or vo- .Ga•r'ryKeU1LDING ME.e_+y.•��,1iF
♦RES IND CON PB OtM.G
prove for purpose of sale.). .,,'?r` � �a•;+�•-ti^f,`-,�q!9,;;:: •� INDUSTRIAL•WASTE INTER , -T,; �3000 -,{ �
❑ 1,as owner of the property.'..exclusively contracting with ❑ a1❑ 3iA❑ ❑ ❑a
licensed mntracton to construct the project(Bac.7044,Business 4• LAWN SPRINKLERS=,-1 INC 5 V B1600 i`S( ASSESSORS PARCEL NO +y .
and Professions Code:The Contractor's License Law don net apply r t K
to an owner of property who builds or improve thereon.�rM who '. 'i LAWN SPRINKLERS•;,,OVER 5(EA.),Sp'1 00 V<,f•,�` ; A,}� g ��
Car
(racts for such projects with a Contractors)licensed punusnt to SEWER-SANITARYEA 21Jpft/1000 .
the Contractors Liana Law. { '. TRALT^NOP ) PATROL NO.,
❑ lam exempt under Sec. ,B&P C:for this yygTER HEATER WNENT_aa.r ^;ti`6 00 'T .
Owner Data WATER SYSTEM • '•.'�` •t -'<5.Q0 - ACC.—DATEACt.FILE N0.3r'
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP- � '5.00 ,n• •3:,, F t-f
'✓`
1 hereby a(fimn that I have a ccr irkiita of consent to self-insure. iONIN .;r
INO ENG.SITE N0."'
or a certificate of Workers'Compensation Insurance,or a artiflN - y
mpy tht.f(S".3800,Lab.C.). .
IVs Policy No. Company . Aw •^'� ^ f A4tE�'T+ThA '
Q \ ❑ Certs&dc by lunnishe 1. v' 4 '-'ts FIRESPRINK ENERGYTN fA
Z ❑ Ce nif c e 'th inspection ivisiaaafififi. MISC.- REFER TO ORD w•'` -1 "I
Applicant Y -0.N❑ -iY�❑ N
~ vee PERMIT ISSUANCE :1000 FLOOD ZONE AUU(L
LU CERTIFICATE OF EX ION FROM WORKERS' y '331 Y �'+ ;
W •{ COMPENSATION INSURANCE PLG.CONTR. m.'... LIG NO.: u PLG.
CL O - - TOTAL ,
:id yyJ';❑ t YQ N�
This section need not be completed if the permit a for ora - - - •_ -s
Z hundred dollars($100)an len.) ' Ztr
U O 1 certify that in the performance of the work for which Ne per, °u,,����y MMM NICAL�PERMIT FEE F ESU Y
LL 1- mit 0 Issued,I shall not employ any person in any manner Pa m to livtIIsl gra. y ttI +"%s«:
U become subject to the Workers'Compensation Laws of Califomia. 0 9 ice+,
U use Date Applicant ALTER OR ADD TO MECH. ..'i 500 +'= BUIL
,RCry'_
} res NOTICE TO APPLICANT: If,after making this Certificate of Ex- -•
F Z emption,you should bemuse subject to the Workers'Compensation APPLIANCE 5.00 'v:? PLAN CHEC I
provision of the Labor Code, you const foM-1. comply wish
U
such provisions ar this permit shall be deemed revoked. AIRHANDUNGl1NIT(TO10,000CF.fA) ;4.00 -i'•; FEE .• '-
( AIR HANDLPJGUNfT(OVERIOAOOC.F.NL) 6.00 -::-i»: . """F7EE '�A :•+'t;-Ayav'�
CONSTRUCTION LENDING AGENCY SETS.MIC�EE��
I•hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) s '6 00 f-,"
sa••�-i yy..
the performance of the work for which this permit is issued(Sec MICROFILM
3097,Civ.C.). HEATING UNIT(TO 10OA00 B.T.U.) 900 :S:•.+ si '"""i° yu'race" ,1,'Zf
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 _�A?-':1� � � €t
Lenders Address - s_LECTTRRIC .r~
I Certify that l have read this application and state that the above VENTILATION FAN (SINGLE) trasppp+ta " tr
-information u connect.I agree to Comply with A city aM county - T sPLUM9ING . '
ordinances and Lute Laws relating to building construction, and BOIL61-COMP(3 H.P.or 10000DB.TU.1'600 vka
�% hereby authorize representative of this city to enter upon.the BOILER-COMP I0",100=MI SEE FEE SCH. �MECHA CAL Y
+`•,s above-mentioned property for Inspection purpoxa
(We) agree to save, indemnify and keep harmkn the City of - MISC.- -- ;%;i .fvjS,.t.REFER TO ORD. ;yr}:: . .�,,..AeAC,.-,y,_N....
Cupertino against liabilities,judgments, 'Ca and expenses which CONST.TAX i
ma in any way accrue neg,eptPsS/see y'ty in Consflume of the PERMIT ISSUANCE -10.00 .,
this perm' . Is'PV'Px 1 MECH.CONT. LIC.NO. r MECH.
r— 1 '0ab b TOTAL ,�TOTAL� 9a�
ignatum of ice ",:ad,ract r D to /
OFFIC_COPY -