4689 /�/-•APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
/ BUILDIN G PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT ,,_,A C89
nooREss / _t 4 v
o ( n y J BUILDING -ELECTRICAL-PLUMBING-MECHANICAL a
C.PER'S `•Ick PLAN CHECK VALIDATION r
NPrM; ' ! r•Ta�' . ELECTRIC PERMIT FEE
7 ( ) ,HorvE , I a i
CONTRACTORS OUTLETS-SWITCHES-RECEP 5.00/1.00 "^:
N ME
v0,, LIGHTING FIXTURES 5.00/1.00
CONTRACTORS
oma
ADDRESS dy PPLIANCES-RESIDENTIAL 4.00
'I0 PHONE .-p��� PANELS 5.00 DATE OF APPLICATON 1
ARCHI cT lJ SIGNS 6.00 PLAN CHECK FEE trP:C.NO.
OR
ENGINEER PrP
LIC,No. SIGNS TRANS. 3.00
AARCH,OR DDRESS ENG. - SPECIAL CIRCUIT 5.0Q PERMIT VALIDATION Y
ZIP TEMP.METER OR POLE INS. 15.00 PA101
APPucANTs
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00 EP U 5 �98s,
0 0 o LICENSED CONTRACTORS DECLARATION Cite
¢ v u I hereby at thus I an licensed under provisions of Chapter 9 I S
N a A (commencing with Section 7000)of Division 3 of the Rroinesz and BLDG. ELECT. PLG.
mm • ME
rmz Professions Cod•,Tnd.my.license is in full force n d(ee.h {- ❑ ❑ ❑
�z o y - License Class-y--,,-.,��L_L Lic.Number
eO? Dmc n• ^ _ Comm,tnr t a .• 1. , .
¢ y s BUILDING PERMIT
¢ ¢ w a OWNIi R-BUILDER DECLARATION INFORMATION
doA � MISC.- REFER TO ORD
w S LL y I hereby al5rm that I am exempt from the Contractor's License vALUAn ON S/FT.
H .. o J Low for the(allowing nmsuP.(Sec.703 1.5,Businessand Professions PERMIT ISSUANCE 6.00
0 � Code:Any city or county which requires a permit to construct,alter. ELEC. LIG NO. '
¢ ¢ a O improve,demolish,or repair any structure,prior to its issuance,also ELEC.
O ¢ reyui¢s the app i<nont for such permit to file a signed statmnent th t TOTAL ,,,ggqE MIT TO
m" he e,licensed pursuant to the provisions Of the Contractor x License p i•
FZQLaw(Chapter 9(commencing with Section 7000)of Division 3 ofthe
F E o
Business and professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ ,- o the basis for Ilse allegedexem soon.Are applicant
to a cion en LS STORtS TYPE CONSTR.
i3m by any applicant torn permit subjects the applictnt toacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
.four more than five hundred dollars(S500).):
❑ 1,as owner of the property,or my employers with wage,as BACK FLOW PROTECT.DEVICE 2,00 ace.GROUP RES.UNITS
their sole com penwGOo,will du 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 Contractor's Licensc Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employee,Provided that such inpvove-
mentsarenotintendedorofferedforsale.l f.however.the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00 h
or improvement is sold within one vear of completion-the owner. 1
builder will have the burden of proving 11.1 he did not build or ire- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00BUILDING USE
prove for purpose ofs:dcl. - INDUSTRIAL WASTE INTER. 20.00 IND CON PB Clear
❑ I,as owner of the property,am exclusively contracting with R ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044.Businux LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL No.
and Prohssions Cade:'file Contractors 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 forsmeh projects with a eontmaeds)licensed pursuant to
the Contractor's license Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I.un exempt under Sec. ,B.&P.C.1'o,this WATER HEATER W/VENT 4.00
reason
Date owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSAFION DECLARATION WATER TREATING EQUIP. 4.00 '
I hereby:I irm that 1 have a certilicale ofconsent to sel Ginsure, ZONING ENG.SITE NO.
ora certificate of Workers'Compensation Insurance.or a certified
COPY the,rot IS 8�PO,Lah.CJ.
� ��L_� , eA-'�,0
_ 1'ohcy No `V I,here ny
❑'Ccrfired cpy'i%'riled rnishrd. FIRE SPR INK ENERGY T44
C) "'OyCertified coPY'is;•f led with tle.fity inspection dirlsion. ,
O ApplicamQ f r lt/x f\'s+-Vn�r-4x /L+.. \� /Setif MISC.- REFER TO ORD. Y ❑' N❑ v ❑ N❑
Frn PERMIT ISSUANCE 6.00 FLOOOZONE A.L.u.C.
� CIiRTI FIC.\'I'Ii OP f:\IiM1'TION PROAf N'ORKIiRS'
LU > COMI'ENSA'1'I0N INSURANCE PLG.CONTE. LIC,NO. PLG. Y❑ N❑ Y E:] N❑
(Phis section need not be completed if the Permit is for one TOTAL
hundred dollars(S 100)or Ic,s.)
U O 1 certify that in the performance of the work for which this pre- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued,I shall not employ any'Person in any num nee x,,as to
U become chyd to the Worked Compcn.mtion Lme,of Calilbrniu.
a Dam ApplienetAL7ER OR ADD TO MECH. 4.00 BUILDING
>_ W NOTICE 'f0 APPLICANT: 11,atter making this Certificate of Iix-
F 2 emption,you should become subject to the Workers'Compensation 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 I0X0 C.F.M.) 3.00
CONS I RUCTION Ll'LADING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby of firm that than is a Construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Cis C.). , .0
I.endeh HEATI NG UNIT(OV ER 100,000 B.T.U.)7.50 ELECTRIC
Lender's AddAddryess
I artily Dim 1 have read this apphCation and shRe th:u the above VENTILATION FAN (SINGLE) 3.00
infnnn notion is correct. I ogre,to comply with :dl city and county PLUMBING ,
ordinances and state laws relining to building construction, and BOILER-COMP(3H.P.Dr100,000B.T.U.) 4.00 y� )
hereby authorize representatives of this city ro enter upon the BOILER-CAMP IDver 100,000 BTU)SEE FEE SCH. MECHANICAL / V L•!
aboveanen Coned property lbnnxpectlun Purposes.
[Wv) agree to s indemnify ad keep hannlcss tit,City of MISC.- REFER TO ORD. _
Cupertino against liabilities,judgmems, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in tonscyucnee of the
granting of this pennil. MECH.CONT- LIC.NO. MECH.
TOp � TOTAL �g
Signature oLlPplieant/Contractor Date OT /f
o
INSPECTOR COPY
I