C4330r APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON �ERMIT NUMBER
BUILDING APPLICATION & PERMIT 4330
oORESs/�
AJ /,-)
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S / / PLAN CHECK VALIDATION
"ante I`1
/�R _/� OTY. ELECTRIC PERMIT FEE
l(., a,,: / I U vHONE L9
NAME croRa OUTLETS-SWITCHES-RECEP 5.00/1.00
NOME z j
95R) A Q0/-//)G uc.rvol/ iT� LIGHTING FIXTURES 5.00/1.00
CONTRACTOR" �;(�/7 �Of'// APPLIANCES-RESIDENTIAL / 4.00
'
ADDRESS I/ '1yt' { q
eb, j_ )I/ 1411 �,��[J CP7bNE J ,I U/� PANELS � 5.00 DATE OF APPLICATION
ARCHITECT SIGNS / 6,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.NO. SIGNS TRANS. j� 3.00
ARCH.OR ENG. SPECIALCIRCUIT / S.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANT E MOTORS SEE FEE SCR.
ADDRESS
_
SERVICE CHANGE 10.00 ))) _
C: o LICC;\SIiD CONTRACTORS DECLARATION S / jn
a U I hereby affirm that I am licensed Under provisions of Chapter 9 / ISSUANCE DATE
m<m '(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F n a 1'rofcesions Coderatid Cha license a in full foae.-arid efyect. t
Z,Om- Licenwtla4�a•=J Lica Nlimbc / Yr' T r - - ❑.` ❑ ❑ ❑
..CI a, 0 Date�- 40 Contractor y / 1 r
¢ Y s -a BUILDING PERMIT
¢ ¢ w 4 OWNER-BUILDER DECLARATION
D REFER TO ORD INFORMATION
A.
3 L r- 1 hereby affirm that I and exempt from the Contractors License. MISC.-
LLoa Law for the following reason,(See,103 1,5,Business and Profcssinnz PERMIT ISSUANCEVALUATION S/FT.
� - y Code:Any city or county which requires a permit to construct,alter. 6.00 ��'? Q
a o improve,demolish,or repair any structure,prior 10 its issuance also ELEG CONTR. LIC.NO. ELEC.
ar
w o¢ requires thm
e applicant for such permit to life a signed stateent that TOTAL - PERMfr TO
S:
m" he is licensed pursuant to the provisions of the Contractor's License
i Law(Chapter 9(commencingwidh Section 7000)of Divismu3 oflhe
Business and Pmf'sslons Code)or thus he is exmnpt therefrom and DTV. PLUMBING PERMIT FEE
¢ r the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n ; $ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(S500r):
❑ 1,as owner of the property,or my employeeswith wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole conimu sntion, 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 who does such work FIXTURES-PER TRAP 4.00 SD,FT FLOOR AREA TOTACACREAGE
himself or through his own employees,provided that inch Calorie
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NCT40UTLET54.00
or improvement is sold within one year of completion,lire owner. GASEA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that be did not build or int- - RES IND CON PB Omer
prove for purpose of sole.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑ ❑
❑ I,as owner of tire wit
e property.am exclusireh contracting h
licensed contractors t) construct the projcd(See. 7044.Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code: I lie Contractor's License Law docs not apply
to ,an wner of property who builds or improves diction,and who LAWN SPR INK LERS-OVER 5(EA.) 1.00
")....acts lot such projects with u CCIIHaClor(s)I'I CFWd pursuanl to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I um exempt under Sec.-,B&RC.for Ibis WATER HEATER W/VENT - 4.00
reason `
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC,FILE NO.
E WORK FRS'CONIPENSA'DON DECLARATION WATER TREATING EQUIP, ;? 4.00 .kt
I herchy atfirm that I have a certificate ofet nscnt tosdGinsum. `x, °S
or a certificate of Workers'Compensation Insuruncl,, ZONING or a certifinlENG.SITE NO.
copy,thcrcyss' seG.t/,0 4ab.e.}`r`C/711 1t'" 1/7 LC.I Illi/) t/ =
Policy"No. //O 1i'lany. - b . .
❑ Certified cop1lis herebpfurnishcd. 1 2- FIRESPRINK ENERGY T.24
Z
� App IitCnttifileU-r�/I�-Illlcd Wiilit the JF�� s�odfi n diviv nl ; Y❑ N❑ Y ❑ N❑
\ �/ �l. �L(I 12 / t r/ L 'i' MISC.- T REFER TO ORO.
+'CLLo CE R'I'II'I CA'114 O p EO E X HNI PI'[ON'IE R O.\I WORKERSPERMIT ISSUANCE 6.00 FLOOOzoNE A.L.UO'
LU 1 COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG. V N Y N
�CL 0 1This section aced not be c mpleted if dire penuit is fur of TOTAL - ❑ ❑ ❑ ❑
hundred dollars IS 100)or less.) o "
U 0 1 certify that in the performance of the work for which,this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H fail is issued, I shall not employSay person in ally/manner so is to
U becotgesubjeeyto'the Workers*CompensaiOLD La s If�alitnla� )
n. Date j / \ ) Applicant f t0 JfI L Lf �JY/!6 ALTER OR ADD TO MECH( 4.00 . BUI L'DING
} m NOTICE 10 APPIACAN'I': II,older making this C,rtil icmc of Es- - -
2 creptfon,you should become subject to the Workers'Conlprnsudion APPLIANCE 4.00 PLAN CHECK- '
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNITATO 10,000C,F.W 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLINGUNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I 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 issued(Sec. I- MICROFILM
3097,Civ.C.L HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Nude
Lender's AddreHEATING UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
ss
Ic,,my thud l llavc read this application and stat,firm the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county BOILER-COMP 13 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
om
rdinances and state laws relating In building conslcliun, and
iereby authorize representatives of this city to enter upon the BOILER-COMP f0ver 100,000 BTU)SEE FEE SCH. MECHANICAL
above.mentioned properly for inspection purposes.
(We) agree to No,. indetnuify a..d keep harmless the City of MISC.- REFER TO ORD. )
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
miry/in any way accrue'against said City in ccrosttpcnce of tiro
granting of this permit.,) / MECH.CONT. .LIC NO. MECH. _
I V.T(L( t 0o LL, 5 •6 -�j5 OTAL TOTAL /J
Sign3dtme of Apphemit/Contractor Date
\ INSPECTOR COPY