6881 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BU LD1 NG PROJECT I DENTI FICATI ON . PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDR Ess I
ID 3(, "i BUILDING—ELECTRICAL—PLUMBING—MECHANICAL 6881
OWNER'$ P LAN CH ECK V A L I DATION
QTY. ELECTRIC PERMIT FEE
• 114v"DrvE 444, 36 e
co TRACTos x NAME /
/J��q �t' LT` JOUTLETS-SWITCHES-RECEP 5.00/1.00
+ W,L�STR /O IV
1 -OM LIC.NO. 0 a 00 y LIGHTING FIXTURES 5.00/1.00 � -
,t CONTRACTOR'SPPLIANCES-RESIDENTIAL 4.00
ADOREss �� C�fOg L''LL. C/ej 03
R r/V C # ONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6-00 PLAN CHECK FEE P,C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADD ESS E "G I' SPECIAL CIRCUIT 5.00 O� PERMIT VALIDATION
/f �\ ZIP EMP.METER OR POLE INS. 15.00
noo ESST sF'C\J Nioz(0,4R 176 MOTORS SEE FEE SCH. + J
2 p SERVICE CHANGE 10.00
o ¢ z
Foo I.ICIiNSI!D CONTRACTORS DI:CLARA'1'IONi5 Q
¢ u h hereby Orono that I am licensed under preoisimn of Chapler'J ISSUANCE DATE
ya N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F w z Professions Code,ag9d my license is in full force nd effect.
a O m— I,iccn.Class_4-1 I.ie.Num her O D — ®_ ❑ 10
O m t w Uate--4_,74_ ' Y crott-or
a r f Cor sni VCTrN BUILDING PERMIT
¢ ¢w a OWNER-BUILDER DECLARAT ON INFORMATION
Aoa " MISC.— REFER TO ORD
X 3 r 1 hereby affirm that I so exempt from the Contractors License .n VALUATION $/FT.
F ¢ o¢ lace for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00 �j =--
Code:Any city or county which mquiresa permit to construct,alter,
p7 3
¢ ¢ ¢ 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O¢ requires the applicant for 9Kh permit t0 file a signed statement that TOTAL {� PERMIT TO
a w m u Ile is licensed pursuant to the provisions of the Contractor's License
F z t
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he isexempl therefrom and OTY. PLUMBING PERMIT FEE
¢ f m the basis for the alleged exemption.Any violation ofSeclion 7031.5 STORIES TYPE CONSTR.
Y — _ by any applicant for a permit subjeclS the applicant to civil penally
of not more than five hundred dollars(S500)J: ALTER-DRAIN&VENT-WATER (EA.) 4.00 „
i❑ 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 the structure is not
intended or offered for sale(Sec. 70x4, Business and Professions DRAINS-FLOOR,ROOF,AREA COND. 4.00
Code:The Contractors License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SQ FT.FLOOR AREA TOTAL ACREAGE
. himself ser through his sewn employees,provided that such Improve-
ments are not intended oroffered for Sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or improvement is Sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BuI LOING USE
builder will have Ole burden of proving that he did not build or owner-
RES ' IND CON HB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20,00
m
❑ 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 ASSESSORS PARCEL NO.
and Professions Code:1'he Contractors License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a cmnractods)licensed pursuant to
Ore Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ IamexemptmWer Sec. ,B.&Pc.fimthi, WATER HEATER W/VENT 4.00
reason
owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that 1 have a certificate of consent to self-insure' ZONING or a certificate of Workers'Compmrsation Insurance,or a certified ENG.SITE NO-
copy thereof(See 3800 Lida C.).
Policy No.�y� ¢apTny STf/C f A__L7-�
O ❑ Ceri lel d copy is hereby furmihed. FIRE SHRINK ENERGY T 24 ,
Z_ Z ❑ Certif copy is fled with the ciy
p Applicant impectima division. MISC.- REFER TO ORD.
Y ❑ N❑ Y ❑ NE)
~ m PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.uc.
CISk'I'I FICCO' OF SATI ON FROM WORKIiRS'
W COMPENSATIQN INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ Y❑ N❑
Z (This section need not be completed if the pernit is for one TOTAL
hundred dollars(S 100)or less.)
L) O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,1 shall not employ any person in any manner so as to
O become subject to the Workers'Comperration Laws of California. h
0.W Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING 1(01"e.1
} Nt NO1'ICF '1O APPLICANT: If,alter making this Certil irate al'
Z emption,you should become subject to the Workers'Compensation APPLIANC 4.00 -PLAN CHECK
(_s provisions of the labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TQ I0=CF.M.) 3.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IQOODCEM.) 5.00 SEISMIC FEE �G+ d
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM -
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name H EATI NG U N IT(OV ER 100,000 B.T.U.)7.50 q
Lender's Address ELECTRIC IX�
I certify that I have read this application and sate that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and County PLUMBING
ordinances and state laws relating to building construction;send BOILER-ODMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this City to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMITISSUANCE 3.00 �' UZ CONST.TAX
may In any way accrue against said City in consequence of the �.
gr tin of this iniL� MECH.CONT. LIC.NO, MECH.
L 11 TOTAL // Ov TOTAL
Sign turlo Apple o012 Ito
arc / IT?a_—�
INSPECTOR COPY