6158 i
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION '
PERMIT NUMBER
RDILDING APPLICATION & PERMIT (C�
15 8
ADDRESS �/
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
0 NFR' sl !�-JL PLAN CHECK VALIDATION
'NAME /1 /I J [�T (�/ QTY. ELECTRIC PERMIT FEE
{T-4 L67 1`1/ PMDNE
CONTRACTORS
NAME O UTLETS-SWITCHES-RECEP 5.00/1.00
G S6Q(7 LIGHTING FIXTURES 5.00/1.00
sec.rvo.
CONTRACTOR OOREss ` - APPLIANCES-RESIDENTIAL 4.00 =
PANELS 5.00 DATE OF APPLICATION
NRC HITECTSIGNS- 6.00 PLAN CHECK FEE P.C.N0,
OR
ENGINEER
� E sec.No SIGNS TRANS. 3.00
ARCH ess ENG SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00 (nL
APPLICANT SMO SEE FEE SCH.
ADDRESS IIIJJJ"""
SERVICE CHANGE 10.00
wo D 1-ICIiNSED CON'I'RACPORS DECLARATION
a v 1 hereby affirm that Ian,licensed under provisions of Chapter 9 ISSUANCEDATE
P, < (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. tPLG. MECH.
F m i PRvfis tar,Code,and m license is in full force and effect. ,
z o m- License ClUss Lie.Number 7\ "N
F D DaIC� 0 Con tractor ❑ '�
BUILDING PERMIT
se¢ OWNER-BUILDER DECLARATION
INFORMATION
AOA MISC- REFER TO ORD
w 3 r I hereby affirm that I am exempt from the Contractor's License
F u o¢ Law for the following reason.(Sec.7031.5,tlusiness and Professions PERMIT ISSUANCE 6.00 VALUATION
Code:Any city or county which reyuiresa permit to construct,alter, H`-0
¢ sr Q Limprova.demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIG NO. ELEC. /�t /
O LL rCynlrf5 lire applicant for SUCK pClnllt t0 file a signed Statement tlul TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor.S License �7� -i
Fzi
Law(Chaptar9(commencing with Section 70000of Division 3 ofthe M4r/
a tlusiness and Profusions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ II m the basis f..the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
ate _ by any applicum lmnsubjects mjccts e applicant loocivil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00 til Sy'�
of not nwm than five hundred dollars(5500).):
❑ I,Us owner ol'the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
((lair sole contpensolion,will do the work,and the structure is not --
immnded or offered for sale(Sc, 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Cndo:'I'hc Contractors License I-aw does not apply to an owner of
property who builds Or improves thereon,and who dries SUCH work FIXTURES-PER TRAP 4.00 O SOt/Y
.,FT�.FLOOR AREA TOTALACREAGE
him
self or through his oven employees,Providsu
ed the( ch improve- '\ / A,[
ons are fol intended or offered for sale l L however,lire huilding GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00 -Z/
or improvement is sold within one year of completion,theowner- GAS-EASYSTEM-OVER 4 (EA.) 100 BUILDING USE
builder will hove the burden of proving that he did not build or im- . . .
S IND CON PB Omer
prove for purpose of Sale.). INDUSTRIAL WASTE INTER. 20.00 RES
El❑ I,as owner of the property,am exclusively contracting with El 11 1:1
II- licensed Contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and I'rofessions Code:The Contractor's License Law does not apply 7 .- 6 �d 6
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 3�6 /9
contracts for such projects with a contractorts)licenxd pursuant m
lire Contractors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ l am exempt under Sec. ,B.AP.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS*COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self-insure. ZONING
or a certilicaurof Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thel (See. QQQQ Lu C .� /
Policy No. 1_4
O ' Certified copy is herby famished. FIRE SPRINK ENERGY T-24
Z ❑ Certified copy is Ilse Ith tire it, uspcctiln dlvixinll.
p X Apphc:ml y7 F/ X -"- MISC.- REFER TO ORD. YE] N Y❑ NQS
� =
CER I FICA 1'Ii OIe EXEMPT ION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.Luc.
LU > C'OMITNSA'1'ION INSURANCE PLG.CONTR. LIC.NO. PLG, p/
CL 0 CL Z (This veli'm need not be completed if the permit is for of TOTAL 0 (fl - Y N� Y[] N�
boodmd dollars($100)or less I
U O 1 certify that in the performance of the work for which tris per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F man
full is issued, I shall nomemploy any person in any manner 1.as l0
b U become subject to the Workers'Compensation Laws of California._
U a Dale Appllcam ALTER OR ADD TO MECH. 4.00 BUILDING a�7J
} rn N'O'I'ICI>'fD AI'I'hICAN'I': It,after making this Certificate of Ex-
F Z clnption,you should become subject to lire 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 1QWOC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10OWGEM.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00 a2
tile] performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC �-o
1 I certify that I have read till,application and Slate that tine above V ENTI LATION FAN (SINGLE) 3.00 �! -
information is correct. 1 agree to comply with all city and army
PLUMBING coub =
ondinunand
ces slam s lawrelating to building construction, and BOILER-COMP(3H.P.or100,0008.T.U.) 4.00
hereby aW....we representatives of this city Na cn upon lire BOILER-COMP 10s.rtOO,000BTU)SEEFEESCH, MECHANICAL
ahovelnentioned property for inspection purposes.
(We) agree to save, indenmify ad keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, Cross and expenses whichCONST.TAX
nmin
y in airy way accrue against said City consequence of the PERMIT ISSUANCE 3.00
granular of till,,permit. MECH.CONT. LIC.NO, MECH.
O- TOTAL S^ -' TOTAL
Signa urcol' pplica it C nlmetor Detc
INSPECTOR COPY