6977 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
BU LDI NG PROJECT I DENTI FICATI ON --Z
Fu7,DING APPLICATION & PERMIT 6977
ADDRESS n / boI1 ' n Qr J3UILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNERS I } ,�, PLAN CHECK VALIDATION
1 QTY. ELECTRIC PERMIT FEE cf� G rf4
r PHONE
CONTRACTORS p UTLETS-SWITCHES-RECEP 5.00/1,00 7G /V'•�}/'�
r p J�CG1G C.rvA y tl LIGHTING FIXTURES 5.00/1.00 h.cs'U w //vd-x
ADDRESS
TORS PPLIANCES-RESIDENTIAL _ 4.00
�-�� PHONE - PANELS 5.00 DATE OF APPLICATION
RGHITECTs PLAN CHECK FEE P.C.NO. I
DR QY Ihq YY�AJA slclvs 6.00
NGINEER U
'11-
LIC.NO. 170 SIGNS TRANS. 3.00
AARCH,OR
DDRESS ENG / SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
�J TEMP.METER OR POLE INS. 15.00
4
avvucaNrs MOTORS SEE FEE SCH.
ADDRESS
�url i CA i ' oio (//
SERVICE CHANGE 10.00
,'02 LICENSED CO RACI'ORS DECL\RA'I']ON
¢ u U I her,by affirm that I an.licensed under provisions of Chapter 9 ISSUANCE DATE
X z
(conmumm�g will, Section 7000)of Division 3of the Bu,mess and BLD 'ELECT. PLG. MECH.
r" w z 1'mfessinns Co and my li cense is in full f incciO Wlgv gr t/
z o in LicenIcC s cGln rrn/L Lie.Number i / ❑
O H w Iymc ( SL�Contracrorf5rc r
< r a BUILDING PERMIT
¢ ¢w.o OWNER-BUILDER DECLARA HON INFORMATION
E a'a MISC.- REFER TO ORD
w 3 u r I hereby alflrm that I am exempt from the Contmtlai s License VALUATION SIFT.
LL
04 Law for lire following reason.(Sec 7031.5.Business and Professions PERMIT ISSUANCE 6.00
Code:Any'cityorcounty which rc4uiresa permiuoconstnu4,ulleq ��,
re ¢ Q p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. w v
D ¢ re(lairex the applicant for such perm It Irl flea signed statement that TOTAL PERMIT TO
u w m u. he is licensed pursuant to the provisions of tire Contractor;.License _
z a Luw lChuptcrlfcmnmcncing with Scarinn 7000)nl'Division 3of the
4 D Ifusiness and Professions Code)or that he Is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ H m the basis for lire alleged exemption.Any violation of Section 7031,$ STORIES TYPE CONSTR.
Ate _ by any applicant for apcnnit subjects IIIc upplicmnt tea civil penally ALTER-DRAIN&VENT-WATER (EA,Y4.00 '
of not more than Cive hundred dollars 155007.): '
Cl I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will d°the work,and•t.c structure is not
'intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR;ROOF,AREA,COND. 4.00
-� Code:"rhe Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who Jars such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided(hut such improve- _
..rents zrenol intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 4,00 `
or improvement is sold within line year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BuaDIN USE
builder will have the burden orpioving that he did not build or im- RES IND C PB Omer
prove for purpose ul sale.,. INDUSTRIAL WASTE'INTER. 20.00
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licenced contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESS SPARCEL NO.
and 1'rol'eesiois Cado:'1'he ContraUuh License Law does not apply
to air owner of property who builds or improves there o.and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contacts f°rsu Licenje ts LwiIIlacontractoil s)IicenxA pursuant To SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NW�
The Cactsf.r of license Law.
❑ l air exempt under S,e. :B.&P.C.for this WATER HEATER W/VENT ' 4.00
Owner Dat, WATER SYSTEM 4.00 ACC.DATE , ACC.FILE NO,
WORK I?RS'COMPI?NSA'I ION DEC[.ARA'I']ON WATER TREATING EQUIP. 4.00
1 hcrehy affirm that I have a certificate of consent to sell=insure. ZONING ENG.SITE NO.
I,,a certificate of Workcri Compensation Insurance.or a cc,tificJ
cnpg 1tco 1 e}a 3ROp,•Ia�b Y.l. -O
ILtI 7 mil rm •
O /❑ Cetlified copy is he by famished. FIRESPRINK ENERGY T-24
Z Z ❑ Certified copy is fled with rhe city inspection division. _ I
MISC.- REFER TO ORD.
Dy. Applicant V❑ N❑ .Y❑ NO
Fy 0 UG el. ' PERMIT ISSUANCE 6-00 FLOOD ZONE A.L.u.C.
CE R1'll'ICATIi OP IiWION INS FROM WORK ERS'
CL COd not he ION INSURANCE PLG.CONTR. u0.N0. PLG. Y❑ N❑ Y ❑ IN L]
D Z hCI undred
section,a, „d not be aunplcl¢I if the pcnnit is for one TOTAL
hu1 dollarsfn tine orlo
U O 1 isissued,
certify that h tire tperformance employ
of the work for which Ibis Pur- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
0 L) mil is issued, I shah not employ any m,a1u in:my manneror as to
U become subject to Ou•Workers'Compensation Laws of California
/
O n Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} m NO7'IC17 TO APPLICAN'C If,after making this Cenipeate of Ex-
emption,you should become subject to the Workers'Compensation APPLIANCE % 4.00 PLAN CHECK '
provisions of The LaMx Code, you must Forthwith comply with FEE s
U such provisions or this permit shm
all be deeed ,M
revoked. AIR HANDLING UNIT(TO 10=C.F .1 3.00
CONSTRUCI ION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.E.M.) 5.00 SEISMIC FEE `•. -�I�
I hereby af1ir I that )here is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
file p,rfoniaiu: of the work for which this permit is issued(Sec. MICROFILM
San,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name4
HEATING UNIT(OVER-1 00,000 B.T.U.)7.50
Lender's Address '- ELECTRIC
I certify that I have read this apphL'atioa and state that the above VENTILATION FAN (SINGLE) 3.00
. information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws nelzting to building construction, and BOILER-COW(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of (his city to enter upon the BOILER-COMP(Over 100,000 STU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, lid ell,an Y�And keep ....less the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgncnts, est and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in an way ac'rµe uguins said Cjty conscyucnce of the
gmnti o'thlsperJr�I. Ir 1 MECH.CONT. LIC.NO. MECH.
-( //'' t I,Ih r (,�. TOTAL TOTAL cis's
Sign re o6Applicant/Contrm for /Sate
INSPECTOR COPY