6241 (3) I APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT:PEN ONLY
zBUI LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDINGV, APPLICATION & PERMITADDRESS 6241
BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
d ^/
O-NE. _ PLAN CHECK VALIDATION
N°ME gsr7/ / QTY. ELECTRIC PERMIT FEE
PHONE
ctCJ
CONTRACTOR'S
NAUTLETS-SWITCHES-RECEP 5.0011.00
ME
uc.'No�/ YO LIGHTING FIXTURES- - 5.00/1.00
CONTRACTORS ,
ADOREss '. = PPLIANCES-RESIDENTIAL 4.00 -
3 ,37/Yob
ONE PANELS ' . 5.00 .+-DATE OF APPLICATION
ARCHITECT SIGNS 600 PLANCHECKFEE P.C.NO.
OR . GX`
ENGINEER - '
tic.Na. SIGNS TRANS. 3.00 _
AARCH.OR DDRESS ENG. -- SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ziv EMP.METER OR POLE INS. 15.00
APvucANrs
ADDRESS MOTORS SEE FEE SCH. v
r }. •.tl. r--'_. - . '.. I.SERVICE CHANGE y. 10.010,Lc
O C0FDO LICENSED CONTRACTORS DECLARATION 6 )
< v eFi I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE -
v,A N (commencing with Section 7000)of Division 3 of the BnxIaCSS and DLDG. ELECT. PLG. MECH.
F M z Professions Code,and By linens'is in full 1'O ce and tinct.
i O m — License Cl g s_,CL�Lic.Number L
9 z r D DateJJCmitracmr
a BEs - - BUILDING PERMIT
Lr BE LE OWNER-BUILDER DECLARATION , "INFORMATION
wo A I hereby sit that Pam exem t from'the Contractors License MISC.- ,, REFER.TO'ORD
3 u F y P VALUATION - $/FT.
uoi Law:for the following rcasoo(Sec 70315,Busirissind Professions' PERMIT ISSUANCE - '6.00 Do
F —
Code Any City of County which re,laires apermit to construct,alter,
LE ra a p it I 4 d I 'h i repair any structure,prior to its is ls
issuance, EL C TR. -LIF ELEC.
G a, I f s the a,pll ml for such p t 1 I 1I signed statement that . dL� j.7 � /��y TOTAL / 7� PERMIT TO
� wm lie is licensed pursuant to the provisions o1the Contractor's license
F z r L [Chapter 9(commencing with Section 7000)of Dllsion3 of the LGA
a Business and Professions Code)or that he is exempt then, 0.and DTV. PLUMBING PERMIT FEE
H $ the basis for the alleged exemption.Any violation of&ctiou 7031.5 STORIES TYPE CONSTR.
a � by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.) 4.00
of not mom than five hundred dollars($500).):
�} ❑ 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 lire structure is not
intended or offered for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:I'lie Contractor's License Law docs not apply to an owner of
property who build%[r improves Ilucreon and who dols such work FIXTURES-PER TRAP'.-. 400 'SO FT.FLOOR AREA TOTAL ACREAGE
h mself or through his own employees,provided that such improve
-
for are;at int nd dioroffered fnrsok.If,however,dh'building, GAS_EA.SYSTEM 1.INC.4 OUTLETS-400 _--....,. ..a.. �., .
or improvement is said within one year of comp) tion,the owner GAS-EA.SYSTEM-OVER 4 (EA.).' 1.00 ?" BUILDING USE
budder will have the burden of proving that he did not build or im-
prove —
forpurposeofsale.). INDUSTRIAL WASTE°INTER. 20.00 .IND CON PB Omar
❑ 1,as o of the properly,v exclusively contracting with ❑ ❑ ❑ ❑ ❑
heenxd contractors In construct the project(Sec. 7044,Hisao... LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The CoNmctor's License Law'does not apply
m an Owner of properly who builds or improves thereein,and who LAWN SPRINKLERS-OV ER 5(EA.) 1,00
contracts for such projects with a eontractoAs)licensed pursuant to
the Contractor's License Law: - - SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ IJm.CCI'n,GGtR1cr See ' ,B.&P.C.lin this WATER HEATER W/VENT . 4.00
reason —
Owner- -Lute WATER SYSTEM 4.00 ACFDATE ACC.FILE No.
WORK FRS'COMPENSA7ION DECLARA9`ION WATER TREATING EQUIP. - 4.00
1 hereby union that l (lave a certificate of consent n :.Il-instar. ZONING
or a certificate of Workers'Compensation Insurance,or a certified - V ENG.SITE N0.
Copy thereof(Sec.3800,Lab.C.).
Policy cy No. Companyl - -`
O ❑ CL led cap, I,hereby furnished. % FIRE SPRINK ENERGY T-24
ZZ utiliedyipy 11,ele ova rc d yuGOl Division.
O Applicant REFER TO ORD. ! ❑ N❑ V ❑ N E]a/ L. Y
c N CERT u'ICA'11:OF I iXIiM PI ION PROM WOR KI.RS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U,C.
LU > COMP(?NSA'1'ION INSURANCE PLG.CONTR. LIC.N0. PLG.
TOTAL,
N Y N
ai O (This sediein need not be com�IrmJ if the peni1id is lin one ❑ ❑ ❑ ❑
0• hu1 Cee iy that 151001 of leis:) '`- ' - -+ " e / .f
LL O I notify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT ' FEE FEE SUMMARY
0 f mit is issued, I shall not employ any person in any manner sr to
U become subject to the Workersm
Cnpensation Laws ofCalifornia..
WDate Applicunl ALTER OR ADD TO MECH. 4.00 BUILDING
0..} to NOTICE TO Ali[ If,alum making this Certificate of E.
H ? eruption,you Should become subject to the.Workers'Compensation APPLIANCE 4.00 PLAN CHECK
Provisions of the Labor Code, you Good forthwith comply with FEE
CJ such Provisions or this permit shill be deemed revoked. AIR HANDLING UNIT(TO 10X0C.F.M.) 3.00
CONSTRUGL'ION LENDING AG17NCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 _ SEISMIC FEE
I'hereby affair I that there is a Corsi,
action I nd ns agency for EXHAUST HOOD(WITH DUCT) .- 7 2.00
Y the perfonotarce of the work for which this permit is issued(See. MICROFILM
4" 3097,Civ C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lerdc-r' Namc
Address Lender's HEATING UNIT(OVER 100,000 B.T.U.P.50 ELECTRIC /7 5v
(• 1 Certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is coronet.1 agree to comply with all city and county PLUMBING
•' ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,0008TU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save indenmify and k(:ggP harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,jmigmefrta,�C6s[s antl expenses which CONST.TAX
may in any way a �tie agail �I 1' in consequence f the PERMIT ISSUANCE 3.00
granting of thi rIL MECH.CONT. LIC.NO. MECH.
' L TOTAL TOTAL
r plicant/Contractor ate
INSPECTOR COPY