6853 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
"BUI LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
RDILOINO APPLICATION & PERMIT
'a I. ss � (- 1� \ BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 6853
1,10/1 eU
NAMEW}•L O/LV CC� �gSS ULI PLAN CHECK VALIDATION
. _ OTY. ELECTRIC PERMIT FEE
vHorvE
IAOCo NTR rolls UTLETS-SWITCHES-RECEP 5.00/1.00
PANE C(,t-NT �'Lunl6//7y
.A (�`� uc.rvo. LIGHTING FIXTURES 5.00/1.00
GorvTHAtroH ' X3(0 7 7� .tR�TP PPLIANCES-RESIDENTIAL 4.00
GRESS
J PHONE . PANELS l_ 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER �" LIC.NO, SIGNS TRANS. 3.00
' ADDRi�ESS Ervc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP 7EMP.METER OR POLE INS. 15.00 � / /�
ao a ANTS MOTORS SEE FE_E.SCH: \/V,7j[`a��
SERVICE CHANGE 10.00
La O o LICENSED CONI RACfORS DECLARATION \• J ���
rt o U I hereby aflirin that I ant licensed under provisions of Chapter 9 ISSUANCE DATE
(comm�emm�g with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
iI'rolussions CoJc,and y Ireenle is in(all forte and effect Z ❑ ❑ ❑
z o�, - Liccnu C s Lic.Nmnbcr \
Q Contractor K m, 1 n L
Q y < J
rc 4 OWNER-BUILDER DECLARAIION BUILDING PERMIT
6 ala n INFORMATION
o A U MISC.- REFER TO ORD
w g LL N, I hereby collo the I am exempt from the Centrucmr's License VALUATION 4/FT.
H .. oJ law lbr the following
reason.(Sce.7031.5.Buonessand Professions PERMIT ISSUANCE 6.00
f °a0E Code:Any City or County which requiresa permit to t".
R 2 ¢ O improve,demolish,or repair any sIruCImc,prior to its issuance,also ELEC.CONTH, LIC.N0.' ELEC.
N u requires the applicant for such penins to file a signed statement that TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions of D¢Contractors License p
Rza
Law(Chapter 9(commencing with Section 7000)ofDivision 3 of the PLO
s 4 o Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢ H p the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
La d � � by any applicant for a permit subjects the applicant to a Civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
Of mol"ere than five hundred dallars(45001.)
❑ 1.as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their Sole compensation,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 Con Raclin's License Law doe,net apply to all owner of �.
Pette try wholo1llls Or tot proves lh ere onand who dolt SllCll work FIXTURES-PER TRAP 4.00 SO.FT.FLOORAREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- 'k
cents are not intended or offered for sale.if however,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 (EA.)` 1:00 BUILDING USE
builder will hxvo the burden of proving Ihat he did not build or iso- RES IND CON PB Orl,er
prove for purpose of sale.). ""' INDUSTRIAL WASTE INTER. 20.00
Cl 1,as owner of the property.3m exclusively contracting with .❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- I INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code The Contractor's License Law does not apply
In am owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) .1.00
eonlracls for such projects will,a cm Oa,mm,'t licensed pursuant to
the Contractors License Law. SEWE -SANITARY-STORM EA.200ft/6.00 j', TRACT NO. PARCEL NO.
❑ lam excnlpt under sec. ,B.&I'.C.for rhes WATER HEATER W/VENT 4.00
• rca,ur
Owner Date WATER SYSTEM 4.00 ,r-b ACC.DATE ACC.FILE NO.
N'ORRIiRS'COMPISNSATION DECLARATION WATER TREATING EQUIP. 4.00
I hemby affirm that I have a Ccr ihcute of consent m sell-insure. ZONING
or a cerlil kale of Workers Compens 1 r�f d ENG.SITE NO.
Copy thereof(See.3x00.1ab.C.1 �'f 7,40,&
Policy No. Company y(t S C 71
O ❑ C- lied copy is hereby fumished� ) FIRE SPRINK ENERGY T-24
Lyy L(
Z Z �yCertiDna:oPY film with t1c p,clion division. '\ REFER TO ORD.
FO Applwaat 1� MISD.- ( V❑ N❑ Y ❑ N❑
m
f,HR'I'IIICATIi OF Iia:.M PTION FROM IVPERMIT'ISSUANCE 6.00 •CrU FLOOD ZONE A.L.U.C.
:RS' -
tlt C MPENSAI'IONINSURANC'Oq PLG.CONTR. LIC.NO. PLG.
0' ('Phis section neer not bl completed I' nepermit is fur one _ � TOTAL •�,. Y❑ rv❑ r❑ No
Z bund reddollees($100 rocs,,.)
V O 1 certify that in the I •rformune the work for%Melt this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mil is issued, I shall not 1plo ny person in any manner sru as to
U become subject to the Wor Compensation Laws of California
UJ
Dom A can -BUILDINGALTER OR ADD TO MECH. 4.00
} ran NOTICE TO API'y ANT. It, ter making this Certificate of Hx-
F- Zcunition,yon odd become soba -t to the Workers'Conipensation APPLIANCE 4.00 ct PLAN CHECK
provisions the Labor Code, yo most forthwith comply with FEE
U such pry- tons or this permit shall be erred rev a AIR HANDLING UNIT(TO 10MC.F.M.) 3.00
CONSTRUC I( LEN AGENCY AIR HANDLING UNIT(OVER 10000 C.F.M.) 5.00 SEISMIC FEE
I hereby mlirnt ThatDew -onstruction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for w 'ch this permit is issued(Sec. MICROFILM
3097,CD.C.L HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 s ELECTRIC
I certify that I have read this xpPllcutinn and state that the above VENTILATION FAN (SINGLE) _ 3.00 t
information is correct. I agree to comply with all city and county PLUMBING (Jb
ordinances and stale laws relating to building construction. and BOILER-COMP(3 H.P.or 100,000 B.T.U.1 4.00
hereby authorim representatives of this city to enter upon the BOILER-COMP love,100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless lire City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which - CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE- 3.00
grantin ;his MECH.CONT. LIC.NO. MECH.
?, OS TOTAL TOTAL
Sig nature of Applin /Contractor a o 1
INSPECTOR COPY