C3392 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
IiiBUI LDI NG PROJECT I DENTI FICATI ON / PERMIT NUMBER
BUILDING APPLICATION & PERMIT I 3392
ADDRESS// .r-� `�
I Rc,�U4T5 W BUILDING- ELECTRICAL-PLUMBING-MECHANICAL �-`
DNAME INNER'SS7 PLAN CHECK VALIDATION tee X� orvE QTY. ELECTRIC PERMIT FEE
8e.1w
7
NOME NTRAcions
NUTLETS-SWITCHES-RECEP 5.00/1.00
N 1, .r�r
W11-10QK �'U� LIC.NO.ot,Oj ��b LIGHTING FIXTURES 5.00/1.00
CONTRACTORS 415 APPLIANCES-RESIDENTIAL 4.00
A/pp)RE$$
r'D•�r �I�w PHONE 88-7/030 PANELS 5.00 DATE OF APPLICATION
ARCHITECT .S•IGN.S• 6.pp PLAN CHECK FEE P.C.N0,
On
ENGINEER \
uc.NO SIGNS TRANS. 3.00
nooa Ess ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
I -- ' --- "'-`- -- • - ZIP-. _ ITEMP.METER OR POLE INS. 15.00
APPUCANT:S MOTORS - -'-'SEE FEE.SCH.
ADDRESS
�'� -- ^-• SERVICE CHANGE 10.00
0 0 0 LICENSED CONTRACTORS DECLARATION )
a L,uv I hereby affirm than 1 am licensed unde,provtot m,s of Chapter) ISSUANCE DATE
a/w (cont......in,with Section 7000)of Division 3 of the Business and B O6 ELECT, PLG. MECH.
F h z Professions C an I Ing license is in full forceryryn��Ili����� ❑ ❑ ❑
- z 0 m - License a_ss Lic.Number_.a4����f-�=
I, ax w Datc � Contract., WW�I�
`a y f _ BUILDING-PERMIT
¢ ¢w o OWNER-BUILDER DECLARATION, - _ INFORMATION
don - REFER TO ORD I
wR I hereby affrm that 1 am exempt from the Contractor i License MISC.- I
LL'O 4 Law far the fieftwing reason.(Sec 7031.5.Busine5sand Professions PERMIT ISSUANCE - VALUATION A 5/FT.
Cnde:Anycllyoocountywhichrequi,esapermit wconst net,alter. - 6.00 y/� 11
Q Q Qr0 unpuct demolish,or repair any structure.prior to Its IsSnanee,also ELEC.CONTE. LIC,NO, �/ r
£LEC.
iL O ¢� requires the applicant for such permit to tile,a signed statement that r y, 1 TOTAL PERMIT TO
LL w es 'IPLJS licensed jnrsoant la the provisions of Rhe Contractor's License
rzi
Law(Chapter 9(comvmncingwilh Section 7000)of DivinuO of Rhe AI
a Business and Professions Code)or that he is,,empt therefrom and DTV. PLUMBING PERMIT FEE .
foo
¢ ro the basis for the ollcged csomplion.Any violation olStt4ion7031.5 -STORIES TVPEONt R.
Ate _ by any applicam fora permit subjects the applicam lnacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of n0R more than five hundred dollars the ap.1:
❑ I,A owner of the property,or my employcos with wages as
BACK FLOW PROTECT.DEVICE 2.00 OCC. -AES.UNITS
inter sole r'o ensaRiun,will(S the work.and the structure is not
Code d e Co7mercd for sale (Sic, 7044, Business and Professions DRAINS!FLOOR,ROOF,AREA,COND. 4.00
Code:The who
builds or License Lew does not apply o.an owner of
property who builds or improves thereon,and who Aucs such work F IXTUR ES-PER TRAP 4A0 SO,IT.FLOOR AREA TOTAL ACREAGE
himself o,through Iiia own employees-provided thin such improve- s
nm tits are not intendedo?offered for sale.H,however,the building GAS-EA:SYSTEM-1 INC.4OUTLETS 4,00
or improvement is sold within note-year of colnpletion, the owner-
b.
wner- GAS-EASYSTEM-OVER 4 (EA.) 1.00 BUILDING builder will have the burden of proving that h . NG uSE
e did not build or it.- - RES IND NG PR DIseI
m 51
prove for purpose of salol. INDUSTRIAL WASTE INTER. 20.00 C1 ElEl El
1,as owner of the property,aexclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSOR P RCELNO.
and Professions oCode:'I lie Contractors License Law docs not appIv
to an owacr f property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
Contracts for such se[.aw.with a contractor(s)licensed pursuant .
the Cont moor's License Lto SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ l at,exempt under Sec.-.B.&PC,fur this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC,DATE ACE,FILE NO,
WORKI.RS'COMPENSA'nON DECLARA'TON WATER TREATING EQUIP, 4.00
I hereby affirm that 1 have/aa,Iy ate ofconsent to wthinsurc. ZONING
or s certificat(ey of N'orj:�r5'{.lpnph ..lion Insurance or a retuned
ENG.SITE NO.
copy thereof f egCg1t00.Laf.C.l. tGv11'-nV`''W,�`-v Ii♦' I F,�u�jAA Nf I I
/ Policy NAU Company
O ❑ Certified copy is hereby furnished. FIRESPRINK ENERGY T 24
At Certified copy is filed with the city inspection division,
Z 0 A11Int MISC- REFER TO ORD. Y ❑ N❑ I Y ❑ No
My CER'HFICATEOFFXGNI''I'ION FROM\40RRIiRS' PERMIT ISSUANCE 6.00 FLOOD ZONE 0.L.UC.
LU > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG,
CL 0 ('this section need not be completed if the permit is for one TOTAL YE] N❑ y ❑ N❑
Z) Z hundred dollar,(SI00)at less.)
U 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
U. F- Init is issued.I shall not employ any person in any manner so as to
V become subject to the Workers Compensation Lass of California.
U CL Date Apple°ant ALTER OR ADD TO MECH, 4,00
BUILDING
} W NOTICE TO APPLICANT': If,after making this Cerlificate of lis-
r 2 emption,you should lice smle subject t.the Workcn,-'Compensation APPLIANCE 4.00 PLAN CHECK
Provisions of the Labor Code, you must forthwith comply with
U such provisions or this perinil shall be deemed revoked. AIR HANDLING UNIT(TO 10)000C.F.M,) 3.00 FEE -
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IQOOOC.EM.) 5.00 SEISMIC FEE
I hereby affirm that there Is a construction lending agencv for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work far which this permit is issued(Sec. HEATING UNIT )TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Cie C.).
Lender's Name
Lender's Address HEATING ON IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I scnify that I ha rad thisappinatwn and r o that the above VENTILATION FAN (SINGLE) 3.00
nu n lion is correct I agree to comply with II City and county PLUMBING?
to an
rnoes and state b elating t building ' t,lnuTi n, and
BOILER-COMP(3 H.P.or 100,0008.T.U.) 4.00
`� here',
ehy amhorD r pr ntativls o1 this city t n upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL.s
above-meat oned property for inspection purposes.
(WIi) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino a ainst liabilities,jud m tits, costs and expenses ,can PERMIT ISSUANCE 3.00 CONST.TAX
may in a ' way accrue ogee t r Id City in conseq •nee f the
g in f is penniL ' ECH.CONT. LIC.NO. MECH.
/a� �S TOTAL TOTAL
Igo pure of pp' an Gnvm for 3 Dale s
INSPECTOR COPY