7288 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT /� ///���
PUDPE55 �` 7288
Y / �LS��� �a BUILDING-ELECTRICAL-PLUMBING-MECHANICAL Gi(/'v
OWNERS \ PLAN CHECK VALIDATION
/ NAME 'I/� CITY. ELECTRIC PERMIT FEE
• VI) PHONE
NAME crDns UTLETS-SWITCHES-RECEP 5.00/1.00
NAME (
ERV M L' LIC.NO, 3I1064 r LIGHTING FIXTURES 5.00/1.00
CONTRACTORS AOOF�� APPLIANCES-RESIDENTIAL 4.00
\' AOOREss AI- ''ll
\ PHON6116PANELS 5.00 DATE OF APPLICATION
ARCHITECT /[�/s� ��/)/y SIGNS 6.00 PLAN CHECK FEE P.C.NO,
ENGINEER 7 7`�
LIC.No, SIGNS TRANS. 3.00
ADDRESS ENc' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00 �7 /
APPLICANT s j MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00 '
w o o LICENSED CONRACI ORS DECLARATION
G U w I hereby uffinn that 1 um licensed mdm pmvisian6 01 Chapter 9 ISSUANCE DATE'
H G N (commencing with Section 7000)of Division 3 of the Business and B OC ELECT. PLG. MECH.
r H z I'rol'essions COAL',and my license is in full force
0 o m -`• License Class S-'Jl�C....Nwtor * e r ❑ ❑ ❑'
0 2 H ti Duro 2 �Lw.N tractor Sa r
H ,n
¢ m sBUILDING PERMIT
¢ BE au a (aWNHk-ItUILDIik UECLA kA'I'ION INFORMATION
K
; LL ,- I bumhy afl'inn OwI I mCi uxcngn Gam the Contracmr's Liccmc MISC-- REFER TO ORD
VALUATION $/FT.
F LL O 4 Law for the following rcuson.(Sec.703 1.5,Businessand Professions PERMIT ISSUANCE 6.00
as Code:Any city or county which requiresa permit toconstrucL alter,
¢ Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- O u squires the upplicanl ler such pa relit to file a signed sDitentent that TOTAL a PERMIT TO
n K z he Is Ilecnsed Pursuam to the provisions of the Contnmtor s Llccnsa
LB i
Law(Chapter 9(commmlmng will,Section 7000)of Division 3 of the
¢ Business and Prol'enssioos Code)or(hill he is exempt therefrom and QTY. PLUMBING PERMIT FEE
BET o
¢ o the basis for the alleged emit subs.Any violation otoectioo 703 L$ STORIES TYPE CO STR.
by Cut
inorlicant fora permit subjects thc0).): ant tnacivil penalty ALTER-DRAIN -WATER IEA.) 4.00
of not more than five hundred dollars($5001.1:
❑ I,as owner of the property,or my employees with wages as, BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES UNITS
(heir sill,cnnhpensation,will do the work.and the s ruclure is not
intended or offered for sale (Sec. 7044, Business slid Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code:"rhe Contractor's License Law docs not apply to an owner of
property whu builds or improves thereon,and who docs such work F IXTURES-PER TRAP 4.00 S0,FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees.provided that such improve-
ment,are Get intended oroffercd fix sato.If.however,the building I GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 (EA.) 100 BUILDING USE
builder will have the burden of proving that he did not build or im - . . .
5 IND CON PB Omer
prove for, vvnc,of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑
❑ L as owner of the property,he exclusively.7044,Bu with
t and Pro contractors :' construct Contractor's
the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
v to an owner
of Code:The Co builds 's License Law hoes not apply
toaniowner ofproperty who buildsorimprovesnsqDion,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a nnnrunorts)liccns6d pursuant to
the Contractor's License law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
11
❑ tum exempt under See. ,RI&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner U ¢ WATER SYSTEM 4.00 ACC.DATE ACC.FILE N0.
I
WORK I'KS'COMPI!NSA'I'ION DECLARATION WATER TREATING EQUIP. 4.00
e I hereby ate(if tort i heve a cernsat at oRoance to set chuffed ZONING
-t or a car(ifica(c df N'orkcn.'Compensation Insurance'or a certified ENG.SITE NO.
cupythcrcof(Sve.3800,Lab.C.1. <A
k
}' - Policy No. Com Puny
Q ❑ Certilierl Cop)'Is crehy fu ed. FIRESPRINK ENERGY T-24
Z Z Certified tpy JJill, w' city inane lion division.
O Applicant4 MISC.- REFER TO ORD. Y❑ No , Y ❑ N❑
h CER1'IFICAT'li UI'EXli " r✓ROM WORKERS PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.C.
LU > CoMl 4' ON INSURANC17 PLG.CONTR. LIC.No. vLG.
- CL 0CL Z (This section need I I le cnnnpleted if the Per nit is for one TOTAL Y❑ N❑ Y❑ N❑
hundred dollars 1 S 100)or Icss.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any I inner so as to
U hccomc subject to the WOrkcrs'Cnnlpcm'ation Lives I'Califirnia.
U n Datc Applicant ALTER OR ADD-TO MECH. 4.00 BUILDING Sz
} ra NOI ICF '1'O APPIACAN'1': If,after making this CcRificute of Rx-
}. ? sorption,you shodd become subject to tie workers'Co...penstion APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you mus( for(hwill comply with FEE
U such provisions or this permit shall be deemed revoke . AIR HANDLING UNIT(TO 10SMC.F.M.) 3.00
CONST RUCTION LENDING A(,FNC AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of (he work for which this pennit is issued(Sec MICROFILM
3097,Civ.G). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Naore
Lender's Acidic HEATI NG UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
ss
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all City and County PLUMBING lo• /
ordinances and state laws relating to huddling cor�.sNaction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby aulhorim representatives of this city to enter upon the BOILER-COMP (Over 100000BTUISEE FEESCH. MECHANICAL
above-mentioned properly for inspection purposes
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and mpenses which PERMIT ISSUANCE 3.001CONST.TAX
may in y way crue against Said City in con.. Bence of the
gr�n flhis nein. I MECH.CONT. UC.NO. MECH.
\ C TOTAL TOTAL
S gnuturc o pphmra
cant/Coctor Da�c D 1p / -
'^, r I INSPECTOR COPY