8427 APPLICANT T,0 FILL IN INFORMATIONTWITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATIONPERMIT NUMBER
auu.OtNa . 4e4
APPLICATION & PERMIT ����
ADDRESS pr �,/J
• T �-- T ---�._ '� BUILDING - ELECTRICAL-PLUMBING-MECHANICAL -
���'. Squireiti'll e
TME�� - '� .• PLAN CHECK VALI DAT ION
," QTY. ELECTRIC PERMIT FEE
PHONES
R .r yy y- / ( y Lr LETS! P SWITCHES.RECE10.0011.00
I NAME Lh1'.t JGy. 4f+r L5,.•, Y.vd. ..
l"Fa uc,Na LIGHTING FIXTURES 10.00/1.00
r ADDRESS 20823, S evens Crekk Blvd. , PPPLI'ANCES-RESIDENTIAL 4.00
12 CI!pertigoPHONE 282-2077--PANELS 10.00 DATE OF APPLICATION
Ac CT PANELS'(OVER 200 AMP) 20,00 PLANCHECK FEE P.C.NO.
DENmNEER LIC,NO, C009175.. _SIGNS TRANS. 3.00
ADDRESS18008 SKYPARK CR. N200 SPECIAL CIRCUIT 5.00 1 PERMIT VALIDATION
TRVTNF CA zip 95714 ITEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS 20823•.Stevens Creek BBivd.MCA Cilpertino CA PAID
SERVICE CHANGE 20.00
- 00 LICENSED CONTRACTORS TECLARATION TEMP.POLE 30.00 n I IAS �^^5
¢�u I hereby al'Onn than I.am licensed under provisions of Chapter 9 A V TUSSUAN E Ay►E4
11, w< n (cunarneu ing with Section 7000)of Division 3 of the Business and BLDG ELECT. PLG. MECH.
1 H N i Professions Code,and my license is in full force and effect. Y�{ C pE�I10 ❑
z o m - License Class Lie Number�qq�� ¢
Pa 9 y r Date Contracturtfe. � i .• -+
¢ m D f1VVVV C - "` " ' BUILDING PERMIT
¢ ¢o i OWNFR-BUILDER DECLARATION INFORMATION
wI hereby affirm that I an exempt from the Contractor's License MISC.- REFER TO ORD
3 o m VALUATION S/FT.
tr V, Law fo the nycitfollowing
ounlyoach c.requires 5.a perminess t to construct.
aeons PERMIT ISSUANCE 10.00
Code:Any city or county which requires p prior i. construct alter.
¢ < intpiove,dentolixh,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC:
O u ctltiucs the applicant for such permit to file a signed statement that TOTAL TO
¢ w m he is licensed pursuant to the provisions of the Contractors License
F z i Law(Chapter 9(commencing with Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
sio
¢ Hp the basis nyafpr Ihe'ullr a dermic cube Any applicant
too ciOn7B3LS STOR "TYPE
by anyapplichanfora permit subjects the applicant toacivil penalty ALTER-DRAIN -WATER (EA.) 5,00 {
oCnpt mom Ntm1 five hundred dollars 155007.): AlIq
7. ❑' I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 .GRouP S S.UNI S
.� their sole compensation,will do the work,and the structure is not
ended
intor offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
1, Code:The Contractor's License.Law does not apply to an owner of
A, ,I properly who builds or improves thereon,and who docs,such work FIXTURES-PER TRAP 5.00 SO,Ft.F REA TOTA ACREAGE
himself or through his own employees,provided that such
improve-.cuts are not intended UnIfered for sale.If,however,the building ''GAS-EA.SYSTEM-11INC.4 OUTLETS 6.00 h/L/
or improvement is sold within one year of completion,the owner- GAS,-EAo-SVSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- -BUI4rDING USE
I prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON Pe Omer
❑ I,as owner of the property,am exclusively cwnractieg with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044, Rosiness LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 sSSUE55ORS PARCEL NO.
p1 anJ Professions Code:The Contractor's License Law does not apply
to an owner ol:property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00'
t contracts for such projects with a contmetor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
+ the Contractors License Law. TRACT NO, PARCEL NO.
❑ tum"cxanpt tinder Scc. .B.&RC.tier this WATER HEATER W/VENT 6.00
:) reason -
<
owner / Dare WATER SYSTEM 5.00 AC .DAtE ACC.FILE NO.
( WORKERS'COMPHNSA'r[ON DECLARATION WATER TREATING EQUIP. 5.00
+�1e I hereby mHur that I have u cerafa,te It consent to III-insuI, ZONING ENG.SITE NO:
}1 or a certificate of Workers'Compensation Insurance,or a certified _
copy thereof ISec.3800,Lab C.).' y'
,J 'Policy No.G�y'-1ry,�N1B (Qjj��j�.��.Q�yy}
117 ;/g+Cert I11EUT'E71�•r� f RusheNl d. 114r +w• - '• - • - FIRE SPR IN ENERGY T-24
Z Z,,; Certified'copy is filed with the city-inspection division.
p1'/ Applicant BAS-OP:UPERTIid0-M MISC.- REFER TO ORD. V ❑ N r❑ N❑
~'rn PERMIT ISSUANCE " " 10.00
� >1 I CERTIFICATEOrIr COMPENSATION
ON FROM FLOOD ZO E A.L.0 C.
W t COMPENSATION INSURANCfi PLD.CONTR. LIC.N0. PLG, Y❑ N❑ Y ❑ No'
t\EL'�-4 1'1'his Section need not.be completed if the permit is for one TOTAL
Z 1' hurdred dollars IS 100)1)[less.)
'U Ott 1 certify that in the performance of the work for which this per- FEE SUMMARY
LL F mit is issued.1 shall not employ any person in any manner w as to QTY. MECHANICAL PERMIT FEE
O wt pt become subject to the Workers'Compensation Laws of California.
M Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W v.� NOTICE TO APPLICANT: If,after making this Certificate of fix. _
F
Z ciopliti you shouldm men
beoonsubject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK- N)' provisions of the Labor Code, you must forthwith comply with FEE
U '} such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 101000C.F.M.) 4.00
A
° CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE n C
k'
k I
hereby affirm that there is a hick construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(See. MICROFILM
l 30 ider's .am HEATING UNIT(70 100,000 B.T.U.) 8.00
(Lender's Name
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
t
Y t" I'.eerily that l leave read Otis application and state than lire above VENTILATION FAN (SINGLE) 4.00
.P.� niformation is correct 1 agree to comply with all city and county PLUMBING
onfnances and slate laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00
hereby,authorim representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL _
above-mentioned properly for inspection purposes.
I ' "(.We) agree to save, indenmify and keep harmless the City of MISC.- REFER TO ORD.
Y Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 'CONST.TAX Qf
maylin any way accrue against said City in consequence of the
gmntingoft ispermit. MECH.CONT. LIC.NO. MECH. '
TOTAL TOTAL s 4-19
ani rat T ontractor Dah. -
INSPECTOR COPY
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