5151 (3)` APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 5151
ADDRESS r/ /j
AD/%/ - COOL 9,9-4 6494 Ado BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
. A�FG7A3 � f/Say'K ..E as -f a
GOrviRAcioHs UTLETS-SWITCHES-RECEP 5.00/1.00
CONT
&-/ / JO uc.No. /7y 00 LIGHTING FIXTURES 5.00/1.00
ADDRESS PPLIANCES-RESIDENTIAL 4.00
CONTRACTORS y
P.0NE -2 f-;' 79 77 PANELS 5.00 DATE OF APPLICATION
RCInTECi ISN-rOSG SIGNS 6.00 PLAN CHECK FEE P.C.NO.
O
OR J r
ENGINEER
uc.NO. SIGNS TRANS. 3.00
AARCH 08 DDRESS ENG. SPECIAL CIRCUIT .i 5.00 PERMIT VALIDATION
ztP EMP.METER OR POLE INS. 15.00
AESMOTORS SEE FEE SCR.
ADDRDDRESSS
SERVICE CHANGE 10.00
woo LICENSED COKI'RACTORS DECLARATION
¢ u, I hereby al'lirm that 1 an licensed under provisions of Chapter 9 ISSUANCE DATE
Q2w
fttnnmencing with Sccl i.n 7000)Df Uivisims 3 ell the&Isuwie'anA BLOC. ELECT. PLG. MECH.
rF"h z I'mfhsxions C I� -d y I'ecnse is in full force and free ❑ ❑ ❑ ❑
z o m License Class 1. Z Lmc Number
Q -w pate_/•3o- 85 Contractor
¢ x f BUILDING PERMIT r
¢ ¢ wa OWNER-BUILDER DECLARA"I ION INFORMATION
Aoa " MISC.- REFER TO ORD
I hereby atlllo that I an,exempt from the Con tmetorr Licemu
X. u H Y P yALUATION $/FT. III
H _ o¢ Law for the a.ermit to
Professions pERM1T ISSUANCE 6.00 y6�d/!
Code:Any city or county which requirese permit to construct,alter, aQQQ
Q =4 0 In1PrOVe,dl'mOI15h,or repair any sVnetnR,prior Ill lfx lS]IIanCC,BIW ELEC.CONTR. UG NO. ELEC.
o ¢ requires the applicant fie such permit to file a signed slaten,cnt that TOTAL PERMIT TO
tc w he is licensed pursuant to the provisions of the Contractors License
Law(Chapter 9(commencing with Section 70000of Division 3 ofthe /-
- a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE /WO-)
¢ F o the basis for the alleged exemption.Any violation of Sect ion 703 1.5 STORIES TYPE CONSTR.
n ; by any applicant for II permit subjects the applicant to a civil Penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00 /
of not more than five hundmd dollm,0500).).
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT, DEVICE 2.00 OCG GROUP RES.UNITS
Lair Wle compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code The Contractors License Law does not i,,Iy to on owocrol'
property who builds or improves Ihurcom,and who(I.CS such work FIXTURES-PER TRAP 4.00 So.FT.FLOOR AREA TOTALACREAGE
himself or though his own employees,provided that such improve-
memsare not intended oroffered for sale.If,however.the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or improvement is sold within one year of completion, the owner- GAS EASYSTEM-OVER 4 IEA.1 1.00 BUILDING USE
builder will have the burden of proving that he did not build or inn- - . RES IND CON PB Omol
Prove for.purpom of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑
❑ 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the. project(Sea 7044,Business _ LAWN SPRINKLERS- 1 INC 5 V:B. 5.00 ASSESSORS PARCEL No.
and Professions Code:'I 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
contracts for such projcctx with n contractoos)licensed pumant to
the Contractor's Liccnxc Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
❑ lam exempt under Src. .N.&P.C.far Ibis WATER HEATER W/VENT 4.00
cas n
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
n WORK FRS'COMPENSA'I ION DECLARATION WATER TREATING EQUIP. 4.00
I hemb
Y de if that I have a certificateCompensation
of consent dh sol ertI vet' , ZONING ENG.SITE N0.
or a cenificute of Workers'Compensation Insurance..,a ctrl[fed
1kppy.Jycryy-4(7sA' 0pQ,Lab.CJ. -
hifs9411d/3 Tor131, pinpany A4GG ,` 71 2NS41,I '
O ❑ .rtilicd copy is hereby'fumixhed. FIRE SPRINK • ENERGY T 24
z Z eRAiu 'hpY is fileyr'ith the city' ins Don Ion.
F_p Applicaln6fF�pp��-xJ� .�Y' Misc.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
irrn CER1'1FICA1'1'OF EXEMPHON FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
UJ �:, COMI•I NSA601,1 INSURANCE PLG.CONTR. LIC.NO. PLG.
CL Z ('Phis well.. need not he completed if the permit is for one TOTAL Y❑ N❑ Y F] NE]
hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per- OTY. 'MECHANICAL PERMIT FEE FEE SUMMARY j
LL j- mit is Issued,I shall not employ any person in any manner ,,as t. h v/3eA'fb's+
U become subject to the Workers'Connpensation Laws of California. `
-O y pale Applicant ALTER OR ADD TO MECH.a . .*� 4.00 BUILDING GJ
} ED NO'I'ICC TO AI'PLICAN'I': If,after making this Certificate of rix-
. FZ emPtim,youxhoubl become subject to the worker C.mpemation APPLIANCE f 17� 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLINGrUN1T TO 10=C.F.M.) 3.00 FEE
CONSTRUCT ION LENDING AGENCY AIRHANDLING UNITIOVER 10=C.F_M.) 5.00 .a• SEISMIC FEE ,Sp
I hereby affirm, that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 7,- 2.00
the performance of the work for which this permit is issued ISce. . MICROFILM'
3097,Cie C.). HEATING UNIT,(TO�1B '.4
00,000'
.T.U.) .00
Lender's Name U
HEATING _NIT•(OVER 100,000 B.T.U.)7.50
Lender's aJress IE LEDTRID
s I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) B .3:00
in(onnation 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.or 100,0006.TAL) 4.00 /
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep hunnless the City of MISC.- REFER TO ORD.
Cupertino a• [list liabilities,judgments, costs Eric expenses which PERMIT ISSUANCE 3.00 CONST.TAX
y i y way' accrue against said City in consequence of the
h an f Ili CH.CONT. LIC.NO. MECH.
/ TOTAL TOTAL 6,l 15,19
iy r o PPlicant ..tractor Dat
INSPECTOR COPY