C8300 APPLICANT*TO FILL IN IKwi;OIATI
I 'RED LINES-- USE'BALL POINT-PEN ONLY
BUI LDI NG PROJECT IDENTIFICATION A' PERMIT NUMBER
BUILDINGfytl` APPLICATION & PERMIT
0
ADDRESS I,
B I ING .,ELECTRICAL—PLUMBING MECHANICAL
8 3 0
OWNERS'
R/ RAY
PLAN CHECK VALIDATION
NA"E P AV,�:
" . 1 1 ELECTRIC FEE
ITDN19,5��A -75- 7
CONTRACTORS
nt oE�YILETS,_SWITCHES-RECEP' idoo/i.00
r ke NAME
lut�N . J 47b r;? e2 LIGHTINGPXTURESii (oI'e 1*:Il10.00/1.00
��qAPPLIAN(JES�7wOESIOENTIAL, • 4.00
oaess
PAN E :. ._11 DATE OF APPLICATION
4ji-C JAJ1A1,C146 ('TffP.ONEJ ir�-o 10.00
A OR In,I IT PPA (OVF �OIOZO)' ' 20.00 LAN CHECK FEE P.C.NO.
ED
NGINEER
LIC,NO, SIGNS TRANS 3.00
PRCH.AVG 62 ZI PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
$O UTN
TEMP.METER OR POLEINS. 20.00
"
-APPLICANT'S
ADDRESS MOTORS SEE FEE SCH.
q-Vtl JA)JAJ r. r SERVICE'CHANGE 2000
In at z
'. 0 0 LRC71NSED CONTRACTORS DECLARATION TEMP.POLE 30.001
Chapter 9
I hereby Jli.... than I a. licensed under o.vixicaniot 4, ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG* ELECT. � 11.. MECH.
p, A
y " 61-1
Poillessions Code,and my license is in full force and effect. a'!70
g, —
, � Liceple Class Lic.Number E
g ti
5' c Date—Contractor—
BUILDING PERMIT
OWNER-BUILDER DECLARATION
ca INFORMATION
I hereby alffirm that I am exempt from the Collr License IMISC. REFER TOORD
I
0 4 0 Law for the following reason,(Sec,7031.5,Businessand Professions PERMIT ISSUANCE t"o VALUATION $/FT.
v, ..1 Code;Any city orcounly which requires a permit to construct,alter,
improve,demolish,or repair any structure,prior to its issuance,also ELECCONTIR. LIC.NO.
ar SE q, ELEC.
E: requires the applicant for such permit to III.h signed statement that TOTAL
se PERMIT TO
he is licensed parsount to the provisions of the Contractor',License
i Law(Chapter 9(emnernempag With Section 7000)of Division 3 ofthe
Business and Professions Code)or that he is exempt therefrom and QTYTPLUMBING PERMIT FEE
at r o the basis for the alleged exempt,...Any violation fS,ction703IS STORIES TYPE CONSTR,
a,
by any applies.,for a permit subjects the applicant tou civil penalty
of not more than five hundred dollars($500).): ALTER-DRAIN&VENT-WATER IEA.) 5.00
D 1,as owner of the property,or my employees with wages as -ujlr
6
their sole compensation,will do the work,and the structure is not BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES..UNITS
intended or offered for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND, 5.0-0
Code File Contractor's License Law does not apply to an Owner of
Property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00
SQ,FT.FLUOR APER TOTAL ACREAGE
himself or through his own employees,provided that such improve-
m prove-
ments are not intended or offered for sale.11 however,the building GAS-EA.SYSTEM-1 INC.40UTLETS 6.00
or improvement is mid within one year of completion,
m plation'the owner-
GAS EASYSTEM-OVER 4 (EA) 200
build,,will have the burden of proving that he did not build or an- - . . . BUILDING USE
prove for purpose of sale.).
RES IND CON PB Omer
D 1,as owner of the property,am exclusively contracting with th INDUSTRIAL WASTE INTER. 30.00 0 0 0 0 0
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- I INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:T he 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
contim,is for such projects with a contractons)licensed pursuant to
[lie Contractors Licatria Law, SEWER-SANITARY-STORM EA.200tt/1 0.05 TRACT NO. PARCEL NO.
C, am exempt under Sec---BAP.C.for this WATER HEATER W/VENT 6.00
lWasm,
Owner Dole WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
2 0 ]ON DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofconsent to wIf-inesure.
Of a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec,3800,Lah.C.),
Policy No Company I a J. I 'd, A 7),
0 jel,711�
0 Certified copy is licneby promshod. FIRE SPRINK ENERGY T-24
pplician is Tied will, lh�cuy ie,psr,ion division. MISC. REFER TO ORD.
Z'Z')4 Y E] NE] Y [:] IN[]
0 A 3�Ccrhf Jr
to CERTIFICA�l I`!`O"1 =XEM1T1ON 17ROM WORKERS' PERMIT ISSUANCE taxto f, FLOODZONE AL.UO.
LU — COMPENSATION INSURANCE PLG.CONTE. LIC.NO, PLG
CL 0 CIO(This section need not he completed it the permit is for one TOTAL YE) N Y F] NE]
:D Z
hundred dollars IS 100)m less.)
U 0 1 certify that in the performance of the work for which this'let- GTY. MECHANICAL PERMIT FEE FEE SUMMARY
ij_ 1- mit is issue(], I shall not employ any person in:my manner so as to
0 0 become subject to the Workers'Compensation Laws of California.
ILI
D. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
GO NOTICE TO APPLICANT: If,rife,making this Certificate of Ex-
emotion,you should become subject to the Workers'C.....I.emiltimn APPLIANCE .5 DO 1,Z It'll PLAN CHECK
o
Er visions of [lie Labor Code, you must forthwith comply with FEE
such no,visicin,or this permit but[be dopmuccl revoked AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONST'RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby alfirul there is a c.muldiven lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this pernib is issued(Sec. MICROFILM
3097,Ci,.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's let's Name
Lender's Address H EATI NG UNIT(OV ER 100,000 B.T.W9.50 ELECTRIC 0
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.on 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
ibove-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CFO CONST.TAX
may in any way accrue against said City inconsequence of the PERMIT ISSUANCE 1�Lao
granting of his , it. MECH.CONT. MECH.
T
7- 2- &,y=Rr- OTAL j � TOTAL /70 6—'
SMnalug of Almlecant/Coulfart
INSPECTOR COPY