C3389 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY l '
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
HOLDING APPLICATION & PERMIT
ADDRESS v __ Z33&9
Zc)67 BUILDING -ELECTRICAL-PLUMBING -MECHANICAL
• OWNER - PLA ECK VALIDATION
NAM ] OTY. ELECTRIC PERMIT FEE
(� V PHONE .
CONTRACTORS OUTLETS-SWITCHES-RECEP 5.00/1.00
NAME
t4j J ,Q 16 f.-.rvG LIC.No: LIGHTING FIXTURES 5.00/1.00
CONTRACTOR
OR's APPLIANCES-RESIDENTIAL 4.00
CONTRA - '
L RpHo.t: PANELS 5.00 DATEOF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEEn
uc.No. SIGNS TRANS. 3.00
noONess.ENa SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP. METER OR POLE INS. 15.00
APPLICANTS .MOTORS SEE FEE SCH. JI
ADDRESS
SERVICE CHANGE 10.00 ID
'00 LICENSED CONTRACTORS DECLARATION
G U w I hereby affirm That I am licensed lender provisions of Chapter 9 '�,i ISSUANCE DATE
N 2 N (commencing with Section 7000)of Division 3 of t CAR, and BLDG. ELECT. PLG. MECH.
H Prolessions Co�jr�ynI y(verse is in full force
License Cuss S,,..ip__l- __Lie Number I V C�rt n�
r m F J• Date Co nt raclor _ J
¢ m s I BUILDING PERMIT
¢ ¢ w ¢ OWNER-BUIL)ER DECf
- INFORMATION
Od - MISC.- REFERTOORD
F.
I- 1 hereby affirm that 1 am exempt liom th C<I met is License
�+ y VALUATION 5/FT.
F .. o a Law for ten following reason.(Sec.7031.5.Bust ne.. rofemons PERMIT ISSUANCE 6.00
Code:Any city or county which requires permit reconstruct,alter, l o-�
¢ Q,Q improve,demolish,or repair any structure,prior to its issuance,ulso ELEC.CONTR. LIC.NO. E6EC. / /� I
OR ¢Ca v-• requires the applicant for such permit to file a signed statement that TOTAL T
w y he is licensed pursuant to the provisions of the Contractor's License '
F Z I Law(Chapter 9(commencing with Section 7000)of Division 3 of the �� I�N✓L�
- ¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE a[
¢ H O the basis for the alleged exemplum.Any violation III Section 70315 1 STORIES' TYPE CONSTR, -
d3$ by any applicant for a permit subjects the applicant to a civil Penalty ALTER-DRAIN -WATER (EA.) 4
m
of not ore than live hundred dollars(S500) . .
J: -
❑ I,as owner of the property,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 structure is not
intended or offered for sale (Sec. 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 wlm does such work FIXTURES-PER TRAP 4.00 so.FTrLOORAREA TOTALACREAGE.
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale.If,however,the huilding GAS-EA.SVSTEM-11NC.40UTLETS' 4.00 .
or improvement is sold within one year of completion'the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 ButLDING uSE
builder will have the burden of proving that he did not build or im- RES IND . CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑
❑ d as owner oI the pmtruct he projeciv Se .contracting044, with
licensed contractors tore Contractor's
project(Sec. does
Business LAWN SPRINKLERS'-1 INC5 V.B. 5.00 AssessORs PARCEL NO.
and Professions Code The Contractor's License Law does not apply
to owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contmetorl sl licensed pursuant to
the Coutraaor's license Ww. SEWER-SANITAR V-STORM EA. 200f t/8.00 TRACT No. PARCEL NO,
❑ lain esnunptunLer Sev. ..B.&P.C.fir Itis WATER HEATER W/VENT 4.00
reason
Date Owner WATER.SYSTEM 4.00 ,ACC.DATE ACC.FILE NO.
WORK Ii RS'COM III;NSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affum that I hie t it irate of cunmm to all=insure. ZONING
' ora cetli0cay� 'v.�'y/y nsali I Insurance,or a certified ENG.SITE NO.
copy lhcIhT'.Gt.l _,��J ).A��,t,��
Policy NL Company WwP�E 1��Y -
Q ❑ SSTtified copy is hereby furnished. t FIRESPRINK ENERGY T 2
�Cv,IHf,d PY is 1 'th the city' inspection division.
Z Z 2 Applicant 1 � -� MISC.- 'REFER TO ORD. Y N� Y ❑ NQ
Fy PERMIT ISSUANCE 6.00 FLOOOZONE A.[_.%)C,
LU CIiRTIP C O SATIO 1'INS PROM WORKIe RS' -
DJ >_ MPE 'Sr\TION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This section need not be completed if the permit is fee one TOTAL Y�. NY NE)
0 2 hundred dollar.($100)or lass.)
U O 1 certify that in the perl'nmtance oIthe work for which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
OL H- mit is issued,1 sball not employ any person in any manner so as to
U become subject to the W'orkeri Compensation Laws of California.
U w Dam A 'plicant BUILDING Q
- a p ALTER OR ADD TO MECH. 4.00
} N NO110E TO'APPLICAN'1':.It,after nwking this Certificate of Ex-
Z emptimt 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 10=C.F.M1 3.00
CONS"I'RUC'f10N.LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE ��X
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD WITH DUCT) 2.00
the performance of the work for which this permit is isv, (Scc. MICROFILM
3097,Civ.C.). t
ING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name Is 4 �x� ��
Lender's Address ING UNIT(OVER 100,000B.T.U.0.50 ELECTRIC
I certify that I have read this application and state then the above ILATION FAN (SINGLE) 3.00
inlonnution is correct 1 agree to comply with W city and county PLUMBING
mchummes and state laws rclaim, to building c natruction, and R-COMP(3 H.P.or 100,000B.T.U.) 4.00
hereby aulhorlzc representatives of this city to enter Igwm file ER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
ab.cv,emtioned Property for inspection purposes.
(we) Sg,cv;to save indenmify and keep harmless the City of MISC. REFER TO ORD.
Cupertino against liabilities,judgments, .,Is ,Ind ex Pennus which - PERMIT ISSUANCE 3.00 CONST.TAX
may in any way arcane against said City in consequence of lire
granting IIS permit. MECH.CONT. LIC.NO. MECH.
L6ev- JC IIF[ TOTAL TOTAL /�3 `Ilk'
S' rue [Applicant/Contrucmr Date ={"�
j" OFFICE COPY