7048 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
I- ADDRESS
OI -SARA70A <SVi1nr/,I ,,J_ BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 7048
OWNER'$ PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
-5ox)JH anY [�1u�Tcoc.Jh�HONE 3�9 -OYLyu
CONTRACTORS OUTLETS-SWITCHES-RECEP 5.00/1.00
�• (�(?.�JUN p,n��'N.:, ucNo.N.���/060 LIGHTINGFIXTURES 5.00/1.00 'i
CONTRACTOR'S
ADOREss .S u:Tc3 Z/3 p PPLIANCES-RESIDENTIAL 4.00
Ce r .SANTR U_. PHONE 7Ll'ZZZ/p PANELS 5.00 DATE OF APPLICATION '..
ARCHITECT SIGNS BAD PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
nooaESS ENG. - SPECIALCIRCUIT 5.00 _ PERMIT VALIDATION
zIP TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
1 SERVICE CHANGE 10.00 /
Foo_/ LICENSED CON"T'RACT'ORS DECLARATION
¢U H/ I hereby all-to that I em licensed under provisions of Chapter 9 ISSUANCE DATE
3 a` (conunencing with Section 7000)of Division 3 of it Business and BLDG. ELECT. PLG. MECH.
F�rz I'rofexsim"Codc,and roy license is in full force and effect.
Z OsoLicense Class „'�,.j Lie.Number�_?b/e°''
0 z r o Dale -T- Conra
tctor n. ❑ ❑ s ❑
a Y f w BUILDING PERMIT
¢ ¢ w 4 OWNER-BUILDER D17CLARA'fION INFORMATION
A o A MISC.- REFER TO ORD
x 3 LL y 1 hereby atfirm that I am exempt from the Cont motor's License VALUATION SIFT.
Fu o 4 Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requiresa permit to construct ager.
QQ j O Improve',demolish,Or repair any Structure.prior to its Issuance.also ELEC.CONTR. LIC.NO. ELEC.
- O myuires the applicant for such permit to file a signed statement that TOTAL PERMIT TO '(r
w �• he is licensed pursuant to the provisions of the Contractor's License ' �p
F z,i
Law(Chapter 9(conumucing with Section 7000)of Division 3 of the V Td,l'i-te Liv C:-
- 4 Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r p the basis for the alleged exemption.Any violation of Scclion 7031.5 STORIES TYPE CONSTR.
ca
Ate _ by any applicant for a permit subjects the applicant Ina civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
Of not mare film,five hundred dollars($50OLL
❑ I,as owner of tm property,or my employees with wages as BACK F LOW PROTECT.DEVICE ostru2.00 OCC,GROUP RES.UNITS
xole conpmnsalion,.will do the wrk,and the structure is not
Imonded or.offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:'The Contractor's License Luse dues not apply loan owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,Presided that such improve-
nano are not intended or offered for sale.11,Imweve,,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
,rovel'anmrPnscofsalu.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB oma,
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS.- 1 INC 5 V.B. 5.00 p ASSESSORS PARCEL NO.
and Professions Code:The Contractor's Liccmx Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts Cor such projects with a contracton s)licensed pursuant to
the Contractor's License Law, SEWER-SA,ITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
ClI:un exempt under sea ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.OATE ACC.FILE NO.
WORKBRS'COMPBNSA"MON DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or u certified ZONING ENG.SITE NO.
F
copy thereof(Sce.3800,Lnh.C.L T 1/�-773 s
Policy No. Company Lm
O ❑ CRtiticdcopyisherebyfurnished FIRESPRINK ENERGY T 24
Z z ti0ed pY is Eled with tlIe city inspection division.
O A Iicant U, PF'L x'r' x MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
N CENT IPICA'l'E 01'EXIi.MPTION FROM WORKERS' PERMIT ISSUANCE 6.00 6 FLOODZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. `(/
d 0 IT his wetiors need not be completed if the permit is for one TOTAL Y ElN❑ Y ❑ NE]
Z handled dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner so as to
U beanne subject to lite Workers'Compensation Lmwsof Cllil'ornil.
0. Duce Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
N NO'T'ICE '1'0 APPLICANT: If,after making this Certificate of Ex-
F z clnpliun,you should become subject to the Worker Compcneation APPLIANCE 4.00 PLAN CHECK
provisions' of the Labor Code, you most forthwith comply with FEE
U 1101.....visions or this permit shall be dee...ed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 3.00
Y CONS'T'RUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10,0(IOC.EM.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
tale pedonotance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT ITO 100,000 B.T.U.) 4.00
Lender,Name HEATI NG UN IT(OVER 100,000 B.T.U.)7.50 r
Lender,Address ELECTRIC
I cernly that I have read this application and same that tine above VENTILATION FAN (SINGLE) 3.00 Pta
inh r nation is correct. 1 agree to comply with sell city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMPI3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100.000 BTU)SEE FEESCH. MECHANICAL
ahuve-nhentiuned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgment%, costs and ex Vunsex which CONST.TAX
fully in any way accrue against said City in con,"Immce of the PERMIT ISSUANCE 3.00
gmuting of this pem.it. - MECH.CONT. LIC.NO. MECH.
/-3-9S TOTAL TOTAL
Sig r ofApplicant/Conlrador
Date
INSPECTOR COPY