6108 .APPLICANT TO,AL'L.IN, INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING r� APPLICATION & PERMIT
ADDREs O
�v, / 13UILDING-ELECTRICAL-PLUMBING-MECHANICAL61
OWNER'S ^- L PLAN CHECK VALIDATION
']&Y 4t)VAI
_ CITY. ELECTRIC PERMIT FEE
rHON�
CONTRACTORS UTLETS-SWITCHES-RECEP 5.00/1.00
NA E
.No. 1 LIGHTING FIXTURES 5.00/1.00
=..dL AONTRADToes �qn/s.yy�.,� e� - ppLIANCES-RESIDENTIAL 4.00 '
m ORE
P...1AV-070900 PANELS 5.00 ' DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE V.C.NO.
OR LIC.
"
' c.No. SIGNS TRANS- 3.00
ARCH.OR ENG. SPECIALCIRCUIT' 5.00 i9M1�^LIDATION
ADDRESS //'"'�,��
�f IIF EMP.METER OR POLE INS. 15.00 a�f`
ADDRESNr's 11 97 ooW,46��W44% MOTORS SEE FEE SCH./4 9veys J1'AI 2''l 1965
ADDRESS faC� r VV 11`7
SERVICE CHANGE 10.00 ` .y
IO"
_00 �LICENSED CONTRACTORS DECLARATION •' O� �`Upel tlllO
C(�
a uu l-1l+hereby�affirm.thar•I am licensed under provisions of Chapter U ISSUANCE DATE
N Q m .(ton�pic us 4 h"Seclion 7000)of Division 3 of the Business and Bkpt. ELECT. PLG. MECH.
y.z !ral'essmnr(4ndgPpnJ�I is in full fare
-o ZZ I-iccnv 0lasyj O�Con Number ❑ ❑ ❑
9 z 5-W Mule'/7/ "7/_? Contractor
a a, T BUILDING PERMIT
Tic rt. OWNIi WI�U,ILDI:R... LAdAT10N
a u. u. , . _ . ex...... F-/ a «- _• INFORMATION
X I'LL N I hereby allum th't I am exempt from the Contractor"License MISC.- "fl EFERTOORD
g PERMIT ISSUANCE VALUATION S/Fr.
a.0 j Lawlor the folio m y which
(Sec 7031 5,Busn o r al�ns 6.00
E WCode:Any city or county which¢yu lure.P i...to construct,u, o' ter.
IC¢ inlpmve,demolish,or repair any xl rurture,prior to its issuance,also ELEC.CONTR.' LIC.N0. ELEG.
-0 rt moluires the applicant lin such permit to file a signed statement that TOTAL - PERMIT TO
n w m U. he is licensed pursuant to the provisions of tire Contractor's License
r z i
Law(Chapter 9(commenciagwith Section 7000)of Division 3 of the eOr
a Business and Professions Code)or that Im is exempt therefrom and OTY. PLUMBING PERMIT FEE /�
D
¢
' a
the chase,for the alleged exemption.Any violation of Section 7031.5
STORIES TYPE CONSTR.
v , by any applicant fora permit Subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00 /
of not mom than five hundred dollmx(E500).):
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the Stmeture is not
intruded or oflilred for sate (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of -
property who builds or improves thereon,and who docs such work F IXTUR ES-PER TRAP 4.00 SO.FT,FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve.
meals are not intended or offered for sale.If,hOWCVCT,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00 _�J��I !0
IT inlprovelncat Is sold within one year of completion,the owner- GAS-EA.SYSTEM--0V ER 4 IEA.) - 1.00 v' BUILDING USE
builder will have the burden of proving that he did not build or for. R IND CON PB Other
prove for imp.scof sale.). INDUSTRIAL WASTE INTER. 20.00
Cl 1,as owner of 19,properly,am exclusively contracting with ❑ ❑ ❑ ❑
'licemcd contractors to construct the project (Sec 7044,Business LAWN SPRINKLERS-1 INC 5 V.8. 5.00 ASSESSORS PARCEL NO.
and Professions Code:'I lie Contractor'sLiceusc Law does not apply
10 an owner of property who builds or improves tbcrcon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ l am exempt under Sea ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE N0,
WORKERS'C6MPENSA'I ION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that 1 hove a cerlifitam of consent to,self-insure, ZONING ENG.SITE NO.
,it a certificate of Workers'Conlpensatiml Insurance,or a cruil'iod
rp ,e 1 3s c.1Ts1ZE'X/✓ CA9P
ial�11 oc fit mislcd. FIRE SPRINK ENERGYT-24
A Z Z �JYf,ertiric it. is tIy the city inspection division.
p Applicant MISC.- REFER TO ORD, Y❑ N❑ Y ❑ No
I-r-yY =ta N'. "' - -.q;• - L PERMIT ISSUANCE ` " 6.00 FLOODZONE A.L.u.c.
� - ❑9R'1'I11 A'TIi OFIrXEh11'1'10 'ROM WORKERS'
v
DJ > COMPENSA1 ION INSURANCE PLG.CONTR. LIC NO. PLG. ,
' 4-It.incompletedp TOTAL Y N V N
_Z) Z sSeli,in necJ mol'be it the ennil is for one ❑ ❑ ❑ ❑
,unJ, tlollars 1S 100)or leu.)
U O 1 certify that in the performance of Ilm work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL I-, mil is issued, I sf i ll nut employ any person in:my rllanner sen as lo
U become subject to the Workers'Compensation Laws of California.
UlDatc Applicant BUILDING
Q. - ALTER OR ADD TO MECH. 4.00
} Or NOTICE TO APPLICANT: If,after making this Certificate of Ex-
♦- Z mnplion,you should become subject to the Workers'Conlpensation APPLIANCE4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply will , FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10000C.F.M.) 5.00 SEISMIC FEE J'a
I hereby affirm tial there is u constructign lending agency for EXHAUST HOOD(WITH DUCT) 2.00
tic pclfo rmmlce of the wdrk bar whist,this permit is issued(Sce. MICROFILM
3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
NHEATI NG UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's NArid,ame s
I certify that I 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 comity PLUMBING
..rdinances and ,at, laws relating m building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby awhurire representative, of this city to enter upon the BOILER-COMP Mor.,100,000 BTU)SEE FEE SCH. MECHANICAL
ubuv,aucntioncd properly for inspection purp.cc,
(We) agree to save. indemnify anti keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
nm' way cr against said City in conscyucnm of the PERMIT ISSUANCE 3.00
•.olio lhi: cnf. MECH.CONT. LIC.NO. MECH.
1014 TOTAL TOTAL
IgnaNre of Applicant/Conlracto ale
INSPECTOR COPY