C3389 (2) APP-LICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY r
BU I LDING PROJECT I DENTIFICATI ON PERMIT NUMBER /
ADDRESS - APPLICATION & PERMIT �3389�
Anon Ess BUILDING — ELECTRICAL—PLUMBING—MECHANICAL � '
zv6o I_ �l/F
u OWNERS PLAN CM OR VALIDATION
"AM QTY. ELECTRIC PERMIT FEE
PPL PHONE
NOMtERACToas
Z „�1 J� OUTLETS-SWITCHES-RECEP 5.00/1.00
L '�Q 6 yv6 LHO.No. LIGHTING FIXTURES (/ 5.00/1.00
�.
CON TRACTORS
ADD APPLIANCES-RESIDENTIAL 4.00
REss '
SC G GR;y PHONE PANELS f,' 5.00 DATE OF APPLICATION
ARRCHITECT SIGNS 6.OD PLAN CHECK FEE P.C.NO,
E NGINEEfI ,I�
SIa � uc NO SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
Zus JTEMP.METER OR POLE INS, r. 15.00
APPLICANTS MOTORS' SEE FEE SCH.
ADDRESS
WS
SERVICE CHANGE - 10.00oo LICENSED CON 'T'RACTORS DECLARATION �/6
Q u u I hereby'iffrin '11311 am licensed under provisions of Chapter 9 - ISSUANCE DATE
w z h Icon.oemelng with Section 7000)of Division 3 of tire Busine and BLDG. ELECT. PLG. MECH,
Pml'coions Cod,.J,mI TY lice rise is in full foreey' 5 ❑ ❑ ❑ ❑
z o v. License C ass L_��Y Lic.Number L+���
o H o. Date .4}}� Contractor o
¢ y s 1 I 'I” BUILDING PERMIT
¢ ¢ ¢ a OWNI!R-BD1 LDI:R DHCLARA INFORMATION
a
°a MISC.— REFER TO ORD
w b I hereby affirm thvl I wn exempt from 'heC q ct r i LicenFe _ VALUATION $/FT.
F u o 4 Law for the following reason (Sec 7031 5,dun s rofessions PERMIT ISSUANCE - L 6.00
Code.Any city or county which requires a permit to construct,alter, /� /_ gyp �/ AJ
rtRQ Q impmve,de'nolish,.,repair any,'acture,prior to its aerial,also ELEC.CONTR. LIC.NO. ELEC.
Erequires
c T¢ req is licensed
the applicant for such permit to file a signed statement that TOTAL ip ldlraTO�,�/ma
w m LL he is licensed pursuant m the provisions of the Contractor's License - �`-Y/JLN /y'.7/t-/+
r i Law(Chopter I)(commencing with Section 7000)of Division 3 of the
Business and 1'al'essions Code)or that he wiser pt therefrom and QTY. PLUMBING PERMIT FEE �� E ,JR 'ar e-&16
re o the basis for the alleged exemption.Any violation of Section 7031.5 STORIESTYPE CONSTR.
w. w— by ariy applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
ol:not more than tivc hundred dollars(S500)J:
"❑ Las 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 stonct r,N 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 who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.Provided That such improve-
ments are not intended In on'ered for sale.ll'.however,tm building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1,00 BUILDING USE
builder will have the burden of proving that he did not build or im
Prove for Inupuscot sale.r. INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB omrr
❑ Las owner of the properly,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5,00 ASSESSORS PARCEL NO.
and P,ov,,ions Codc:'I lie Contractor's Li¢nsc Law duce not apply
to an owner of property who builds or improves thereon,and who LAWN SPR INKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contrzetods)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT No. PARCEL NO.
❑ l an,exempt on der Sec. ,B.&I"C.I'o'.this WATER HEATER W/VENT 4,00
reason
Date Owner's WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK I:RS'COMPENSArBON DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have'I c Nificate of Corvert to self—insure. ZONING ENG.SITE NO.
so a cerliflta o N F'r ,neat ion I'tsunmce,nl r Iru�lil"n•d
so
th„.,Jw f(9.,
O �r Policy N Compunl' -
/A ❑ Ce,lifiedcopyish are by l'oil'isled. FIRESPRINK ENERGY 24
z Z -f•]-Cenif'ied copy is lite with the city inupec'ion division.
t/1�n MISC.- REFER TO ORD.
O Applicant ,TV`^}^`®y, Y ❑ N❑ V ❑ N❑
Fm\ ` ' 'PERMIT ISSUANCE 6.00 FLOOD ZONE - aL.0 c:
CC CI:R1'II'CA'1'E OF EXEMPTION FROM WOR61iRS'
LU 1 LC )IPP 'SATIO.N INSURANCE PLG.CONTE: LIC.NO. PLG.
CL ❑ ('I his section need mol be vonmleted if Ilic permit is for one TOTAL Y❑ N❑ Y ❑ N❑
D Z Iumdreddollars(S 100)or lcssJ _
U 0 1 certily [hat in the performance of the work lir which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued,I shall not employ any person in tiny manner so as to
U b,con.csubjccl to the Workcri Compcnsaliun Laws of Cdil'un.ia. BUILDING /7
a Jram Applicant ALTER OR ADD TO MECH. .4.00 'S-0} m NOTICE TO APPLICANT': If,after making This Certificate of Iix-
F 2 ,option,you should Recur,',subject to the Workcri Con.pcnsa'ion APPLIANCE 4.00 PLAN CHECK
Provisions of the Labor Code, you nwst forthwith comply will, FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONS'fRUC'I'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=1C.F.M.15.00 SEISMIC FEE
I herebyaffirm that There is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work tie which this permit is Isv ed(Sec. MICROFILM
3097,Civ,C.) r _ _. t, HEATING UNIT(TO 100,000 B.T.U.) 4.00
LeRdcr',Name, .�.4tiL fi,JLIlLr' Y HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that l have read this application and.state tlun'he above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and County' PLUMBING
ordinances and state laws refuting to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby antlion c rcpresuntatives of this city to enlcr upon tie BOILER-COMP lover,100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for mspecoon purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against Iiabinh ice,judgments, costs arid ,sponse,which CONST.TAX
...ay i any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
grantia, t INS permit ` 1I f / MECH.CONT. I.C.NO. MECH.
�i. OAM e -�NILLt ✓S �IJ1 (\ TOTAL TOTAL
\\ Signature of ADD
'Date
INSPECTOR COPY
I