6499 ,i
i
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY t ..ys
BUILDING PROJECT IDENTIFICATION n•PERMIT NUMBER
BUILDINGAPPLICATION & PERMIT '
ADDRESS 6499
r •yy 2121 Lffidy Lane BUILDING-ELECTRICAL-PLUMBING-MECHANICAL P OZER'S PLAN CHECK VALIDATION
6: - QTY. ELECTRIC PERMIT FEE
CO17.1 ERACTORS PHONE _ UTLETS-SWITCHES-RECEP 5.00/1.00
NO. - LIGHTING FIXTURES 5.00/1.00
TRACTORS - APPLIANCES-RESIDENTIAL
A6
MESS
v E _ PANELS 5.00 DATE OF APPLICATION
C' NrtEOT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OEII NEER 4y..
LIc.NO, SIGNS TRANS: 3.00
ArycH:OR ENG. PERMIT VALIDATION
A s _ SPECIALCIRCUIT 5.00
AF
xtV ZIP TEMP.METER OR POLE INS. 15.00
APPucgrvrs MOTORS SEE FEE SCH.
gooness..e '
•- qnn Ingle, CA Qq .11 SERVICE CHANGE 10.00 -
I o o LICENSED CONTRACTORS DECLARATION
a: v,u I hereby affirm that 1 am licensed tender provisions of Chapter 9 ISSUANCE DATE
iN'�"" (commencing with Section 7000)of Division 3 of the Business and
fAn7 ¢ BLDG. ELECT. PLG. MECH.
y Pr,l ssiuns Cnd anA 7iry license aN full faro u d it
Zro.H Lu .(..Cli ss_ _85 .(S43-L'' Num'at _ -_� ❑_ ❑ ❑
H _ _ �... -.e-•-- _.
'a a f BUILDING PERMIT
' rc ¢ a OWNER-BUILDER DECIARA'IIDON
A o o U INFORMATION
w g LL 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
.F .. oJ Law]'or the f..B..ngreason.(Sec.7031.5,Businessand Pmfesions PERMIT ISSUANCE 6.00 VALUATION $/FT.
Code:Any city or county which requires d permit to conslrucl,alio.
K ¢Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTIL LIC.NO. ELEC.
O¢ rapures the applicant for such permit tU file a signed statement that TOTAL PERMIT T
A w m he is licensed pursuant to the provisions of the Contractor's License
Hza Law(Chapter 9(cumm,rcingwith Section 7000)ofDivision3ofthe MEc
¢ o Bbsines and Professions Code)or that he is exempt Iheretrmn and OTY. PLUMBING PERMIT FEE
BE I- p the basis for the alleged exemption.Any violation of5ection 7031.5 STORIES TYPE CONSTR.
A _ tipp re any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN VENT-WATER IEA.) 4.00
Uf nol mothan five hundred dollars($500).1:
t1❑ I,as owner of the properly.or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
heir sole compensation,will do the work,and the structure is not _
ioimuled or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractors License Law dots not apply to air owner of
.pA)perty who builds or improves thereon,and wbo docs such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
Rh uself or through his own employees,provided that such improve-
4 . III-Ne are not intended or offered for sale.JL however,the huilding GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
.I;•O' !o 'improvement is'sold within one year of completion.the owner- GA$-EA.$VSTEM-OVER 4(EA.) 1.00 'BUILDING USE
n ilder will hove the burden of proving Thai he did not build Or int- RES IND CON PB Other
v E, vc 1,as purpose of axle.). INDUSTRIAL WASTE INTER. 20,00 ❑ ❑ ❑ ❑
IF I] I,as owner at the property,am exclusively contracting with
I ai mise, comracmn to construct the project(Sec 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
,and Professions Code rise Contractor's License Law does not apply
ID lot owner of property who builds or impn)vcs there.....and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts forchar's l lirmLicense
with a contract..rf sl licensed pursuant In SEWER-SANITARY-STORM EA.200ft/8.00 TH ACT NO. PARCEL NO.
We Conlra9uri License Law.
❑ lam exempt under Sec. ,B.&P.C.for ibis WATER HEATER W/VENT 4.00
rc:non
Owner Bate WATER SYSTEM 4.00 A~ACVDATE ACC.FILE NO.
f WORKFRS'COMPENSAI ION DECLARATION WATER TREATING EQUIP. 4.00 `
I hereby ittimn that I Imre.urOhval,of clecout I ,If x m.
ZONIN'G; ENG.SITE NO. s
or` Certificate of Work rs'Compensutmn Insurance or a certified
policy
Noenf lSe 3800,Comps y Y� s
Zoll Y h,. < InpollY
..{��0_ ❑ Cetlil'ed ropy I'1 e ehy fp d sh d -Flh ESPAINK ENERGY'T 24'',:
z ❑ Certified copy rs filed with the city inspection division MISC.- REFER TO ORD.
O ( .Applcant '�❑.^H❑ Y ❑ N❑
rn o PERMIT
J1ISSUANCE 6.00 FLOODZONE A.L.U.C.
-� CERTIFIC1I I*OF EXEMPTION FROM WORKERS' .1
( W DR CO'iPENSATION INSURANCIi \ PLG.CONTR. .� LIQ NO. PLG. V N� Y N❑
= ZEl
1'I his seelion Iced not be complete(] if file permit is for one TOTAL
hundred dollms IS 100)or less.)
i U O .I certify that in the perfonnvae of the work for which this per- QTY. MECHANICAL PERMIT V FEE FEE SUMMARY
LL F mil is issued.I shall not employ any person in any manner so as to
� U beeUme subject to the WorkeLd Compensation haws of California.
M Dene AI,NI°am - ALTER OR ADD TO MECH. 4.00 BUILDING
} N NO')IC[ 'O APPLICANT: If.after making this Certificate of Ex- _
F ? 'emption,you should become subject In the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
!• pro I m of tf l abo Cole, You tr t1 forthw th comply with FEE
I U s ch pro imons or this permit II.11 be decared evoked AIR HANDLING UNIT(TO 10p00QF.NL) 3.00
. CONsrRUCr]ONL1"1DINC.Ac2NCY
'AIR HANDLING UNIT(OVER 10,000C.EM.15.00 SEISMIC FEE
J.
w I hereby affirm that their is ol-truclimI I ntiIg agency for EXHAUST HOOD (WITH DUCT) (- -2.00 -
' mance oflite work for which this permit is issued(Sec. �- MICROFILM
-
.3the performance
Civ C.), HEATING UNIT IT 100,000 B.T.U.) 3.00 ''
Lender's d1e
AdH EATI NG UN IT(OVER 100,000 B.T.U.P.50
;Lender's Address ELECTRIC
..11 certify that I have read this application and state oro,the above VENTILATION FAN (SINGLE) 3.00 / b
l..1'ormation is correct. I agree to comply with all city and colony PLUMBING
.,ordinances and nate laws relating to building construction. and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representativesec this city m elver upon the BOILER-COMP(Over IM MO BTU)SEE FEE SCH. MECHANICAL S
hereby authorize
ioned property Reprefor sentatives
ofth i purposes.
�) (We) agree t0 save, indemnify and keep harmless the City of MISC.- REFER TOORD. ,)
I Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE pv 3.00 '3-00'
CONST.TAX
\A may in any way accrue against said City in consequence of the 16
R} granting of this pemUl. MECH.CONT. LIC.NO. MECH.
' 0 - 7-15-85 TOTAL $ TOTAL
Signature of Applicant ontructor Data Parker Sheet'.Metal 214669
0 INSPECTOR COPY ;r
x ,