C8666CANT TO FIL
INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
-
APPLICATION &PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
X8666
ADIDRfS$
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NAME W4 {{q� 4V/
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/ %am� H, CT; I
r( m
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
'
DATE OF APPLICATION
CONTRACTOR'S '1
NAME -
UTLETS- SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.0.0/1.00
CONTRACTOR'S \
ADDnEss -' ^4 `rt� I/
} f
{
APPLIANCES - RESIDENTIAL f 4.00
PANELS - 10.00
ARCHITECT
oR x r�p,i�Ctf•�0 �
NGINEER
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
END '/
ADDnEss
II ZIP
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
/--. EMP. METER OR POLE INS. 20.00 !.
APPLICANTS
ADDRESS NO
MOTORSMOTORS SEE FEE SCH.
CHANGE 20.00
rSERVICE
�•'�
LICENSED CONTRACTORS UECLA ATIO
TEMP. POLE 30.00
I hereby affihn tl't I am licensed under provisions of Chapter 9
(coni mencing with Section 7000) of Division 3 of the Rosiness and
P(ofe"mrs Coda, and my llee...c is in full ft..ct' ana effect.
License Class Lia. Number
ISSUANCE DATE
t
BLDG. EL�qECT.
❑
PLG. MECH.
Date Contractor
I
la
- OWNIiR-BUILDERD CLARATION
I hereby eullowiltat I mn exempt from the Contractor's License
Law l'orthecity or (Sec. requi3, 5.Business in Prokssions
Code:"Any city or county which requiresapermiuo tSdruct,altec
Improve, demolish, Or repair any Save are, prior 10 Its Piouto1Ce, also
rttluires the applicant for such permit to IIIc a signed Statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9 ( commencing with Section 7000) of Division 3 of the
BUILDING PERMIT•
INFORMATION
MISC.- REFER TO ORD i�
pERMI ISSUANCE 10.00 0
VALUATION
$/FT.
ELEC. CONTR. -,,e LIC. NO.
y�
ELEC. 'i
TOTAL ao9
PERMIT TO
Business and Professions Code) or that he is exempt therefrom and
GTY. PLUMBING PERMIT FEE
�{/ ✓v I��/
the basis for the alleged exemption ny' iolation of Section 7031.5
by any applicant for a permit wbj 01 i1oapplicant On civil penalty
of not more than five hundred dollars fS500).1:
STORIES
TYPE CONSTR.
i
ALTER -DRAIN -WATER (EA.) 5.00
❑ I, as owner of the property, or my employees with wages as
their sole compensation; will do the work, and the structure is not
ocC. GRouP
BACK FLOW PROTECT. DEVICE 4.00
R 5. ,NITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code The Contractor's License Law does not apply to an owner of
FIXTURES - PER TRAP 5.00
GAS- EA.SYSTEM - I INC.4 OUTLETS 6.00
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improv
mentsarenotinlendedorol'fend for sale. It. however, the holdinge-
SO. FT, FLOOR AREA
TOTAL ACREAGE
,
or improvement is sold within one year of completion, the owner-
builder will have the burl2n cif Dr➢•u[Ima- that he did not build or -
prove for purpose of sale )`, +�f�"�
❑ I, as owner of the properly, am exclusively contracting witlt
. ..
GAS - EASYSTEM -OVER 4 (EA.) 200
BUILDING USE
RES IND CON PB Other
INDUSTRIAL WASTE INTER. 30.00
licensed cmnra'ctors to construct the project (Sec. 7044, Business
and Professions' (ode: The Contractor's License Law docs not apply
to an owner of property who builds or improves Oereon, and who
LAWN SPRINKLERS- 1 INC 5 V.8. 6.00
LAWN SPRINKLERS - OVER 5(EA.) 1.00
AZSORSPARCRO.
3J[^
contracts for such projet(s with a contractorts) licensed' pursuant to
th-o Contractor's License Vw, ���
a a❑nlatheseM tunder-Secr ,BAP.C. for thus
J
TRACT O. PARCELNO.
SEWER-SANITAR V -STORM EA. 2001t/10.00 / 0
- / WATER HEATER W/VENT �:. 6.00
Owner dwegiet qC 6no,Date -
WATER SYSTEM _ 5.00 S
ACC. DATE
ACC. FILE N0.
WATER TREATING EQUIP.. 5.00
N'ORKIiRS' D,111 f19N�$ATION'DEC .ARATION
I hereby affirm that I ve a certificate of consent its %elbinsure
or a certilic to of Weill,...�i4ompensation Insurance, or a ceruficd
copy thereof 1Sce. 3800, Luh.CJ:_
ZONING
ENG. SITE NO.
Policy No. Company
❑ Certified copy is hereby furnished.
O Certified copy ie filed with the city inspection division.
Applicant 1
FIRE SPRINK'
V ❑ NE]
ENERGY T-24
Y ❑ NE]
MISC. - REFER TO ORD. E
CER'TIPICA'l' 1: OOIj,EXEMPT10N' PROM WORKS. RS'
\! COMPF:NS/yTIO,�"INSURANCE
(This section need not be mmpleled if the permit is fur ane
PERMIT ISSUANCE 10.00 /0
FLOODZONE
Y N
O ❑
A.L.U.C.
V N
❑ ❑
PLG. CONTR. LIC. NO.
PLG, /0 Pv
TOTAL
hundred dollars IS 100) or lest.) ,
\ I certify that in the performance of the work for which this per-
Intl is issued, I shall not employ mry,Pcrsoo in any Toler so as to
GTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers' Compensation Laws of Culil'orni,,
DateApplieam I -
ALTER OR;ADD TO MECH. 5.00 I�
NOTICE TO APPLICANT: If. after making this Cerlifitme of Ex-
APPLIANCEi 5.00 y
PLAN CHECK
FEE
emption, you should become suhjectto the Workers' Compensation
provisions of the Labor Code,'you most forthwith comply with
such provisions or this permirshall be deemed revoked
AIR HANDLING UNIT (TO 10=CF.M.) 4.00
AIR HANDLING UNIT (OVER 10MC.EM.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
'I hereby affirm thmihere is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit �is i sued (Sea
3097. Qv.C.). )
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00 -�
Lender's Name c
Lender's Address
HEATI NG UN IT ER 100,000 B.T.U.) 9.50
ELECTRIC
1 certify that I have read this application and state (11.1f be above
m( ation is correct. I agree 10 comply with all city and county
urdrinces and stat, laws lelating'to building construction, -and
hereby
this, city to enter upon theabove
mentioned property tali sp of thi .city to
hereby enthoriau roperty for ins inspection
VENTILATION FAN (SINGLE) 4.00
PLUMBING
/e 7
BOILER-COMP(3 H.P. or 100,000 B.T.U.) 6.00 1
BOILER-COMP IOVar 100,000 BTU) SEE FEE SCH.
MECHANICAL
3
(We) agree 10 save, indemnify and keep harmless the City of
MISC.� REFER TO ORD.
Cupertino against liabilities, judgments, costs and expenses which
may in al way accrue against said City in consequence of the
ran"
gran lin this permit Va. r�
-,
n" Apph ant/CoNractoq / Uat
PERMIT ISSUANCE 10.00
CONST. TAX
MECH. CONT. LIC. NO.
MECH.
TOTAL 3 fK
TOTAL
^t-
.•i;y" f •• INSPECTOR COPY >, -A 21