6899 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
SOILDING APPLICATION & PERMIT ^�^^
ADDRESS
/`�.S-0 V-t e AVE BUILDING -ELECTRICAL-PLUMBING -MECHANICAL byy
OWNER'S PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE -
CONTRACTOR'S
NAME fKCe Yys'83qOUTLETS-SWITCHES-RECEP 5.00/1.00
( T• Iw ARO TTA LIC.No. 0 7 LIGHTING FIXTURES 5.00/1.00
AUUNESSrSm 3/CONTRACTORS CAl4(MF(C CAP APPLIANCES-RESIDENTIAL 4.00
PO, � (SM0 PHONE 3711-Zdf PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
AARCH,OR
DDRESS ENG. w SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
APPLICANTS �f'DO � MOTORS SEE FEE SCH. [\JVT/1'/r/'{/�"�
ADDRESS
ItSO 3s �AM - SERVICE CHANGE 10.00 ¢ d-
0 o LICENSED CONTRACTORS DECLARATION
J�3/"
c Or 1 hereby affirnt that I an licensed under provisions of Chapter 9 ISSUANCE DATE
waw (commencing with Section 7000)of Division 3 of the Ilusiness and BLDG. ELECT. PLG_ MECH.
F m i Professions Code,and my license is in full fore and effect �1�1I ❑
o z u, o Liccnsc Class_p��Lic.Number MT
DaleContractor 4 -^^.•
<_. MPftO I BUILDING PERMIT
¢ ¢ w ¢ OWNf.R-B UILUISR DHCLA RA'1lION• I't INFORMATION
0, 0 MISC. REFER TO ORD "
w D u N I hereby'affirm that I am excm pt from the Contractor's License VALUATION $/FT.
H e_ u J Law for the fallowing reason.(Sec 7031.5,Business anJ Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to constructalter,
IS au¢ O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO' ELEC. /
A w
-0¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
m" he is licensed pursuant to the provisions of the Contractor's License
H z i Law,(Chapter 9(comencing with Section 700()ofDivuPLUMBING PERMIT FEE ion 3 ofthe �QC) U
¢ Busm
ness and Professions Cod,)or that he is exempt therefrom and OSY.
¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 l` STORIES TYPE CONSTR.
by any applicant Is),a permit subjects l he applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00 / S AA
of not ..,if....five hundred dollars(5500).):
❑ I,It,owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 2.00 M1 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the Grueture is not
Mnded or offered for sale (Site. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 _ 3 III �..,,,,
e:1'lie Contractor's License Law does not apply to an owner of
Property who builds to imp nrse,thereon,and who docs such work FIXTURES-PER TRAP 4.00 SO.FT FLOOR AREA TOTALACRFFppGE.
himself or through his own employees,provided that such improve- . tj
memsare not intended or offered for sale.Iflaowe,er,thebuilding GAS-EA.SYSTEM-11NC.40UTLETS 4.00 3-2 (/
or improvement is sold within one year of completion,lire owner,
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
prove lot purpose ofsale.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB Omer
❑ I,us owner of the property, r n ❑ ❑ ❑ ,❑
P p- y,and rojectiv Se contracting with
licensed contractors to he
the project(Sea.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL No.
and Profusions Code:The who
builds s License Law docs not apply
to Contract,
owner of property who builds tr improves
ensed p.and t to LAWN SPRINKLERS=OVER 5(EA.) 1.00
tine Co t lar such projects wish a contractor[sl licensed pursuant to -
thcCommnor'sLicenseLaw. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under see. ,B.&P.C.Iia this WATER HEATER W/VENT 4.00
wine
Owner Date WATER SYSTEM 4.00 ACG DATE ACC,FILE NO.
\WORKERS'COMPENSAI[ON DCCLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that l have it cerlilicale o(cnnsent to selpinsme, / ��.� /GJ.7 ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy themirf(See 3800,Lab.OL LA-f.
Policy No. Company STA-�'�-may
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z 2 ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant? ''- -Fse1LA(2w,gr -/-(�L� _ Y❑ N❑ Y ❑ Is[3
ri ! T I_ Pf / PERMIT ISSUANCE 6.00 sFLOOD ZONE A.L.U.C.
Ir R PI A E( 'SA [ ION FROM WORKERS'
W need not be [ON'INSURANCE the PLG.CONTR. LIC.N0. PLG. Y❑ N❑ Y❑ N❑
O (This sectiondollars need not he completed if the permit is for on, TOTAL O
Z ,IIIIIdred dO 'JIb(5DD1 ar less
U O 1 certify that in the performance of the work for which this per, QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F ntit is issued, I shall not employ any person in any manner so as to
0 heenlne subject to the Workers'Compensation L,.,of Califomiu.
O w BUILDING 3 C
n ])at,_Applicant ALTER OR ADD TO MECH. 4.00 � 0
} 0 NOTICF *TO AI'1'LICANT' If,after making this Certificate of Ex-
Z + enlpt un,you should hemine subject to the Workers Compensation /,APPLIANCE 4.00 PLAN CHECK
provi,ims of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit ilia[[be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCHON LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE A;K0
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
IIIc performance of the work for which this permit is issued(Sec. - MICROFILM
3097.Civ.0 f ( HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name H EATING LIN IT(OVER 100,000 B.T.U.17.50
Leader',Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
feinformation is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating m building construction, and BOILER-COMP(3 H.P.or 100,0008.T.U.) 4.00
hereby authorise representatives of this city to cmer upon the BOILER-COMP (Over 100,000BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, ind.unify and keep hamlets the City of MISC.- REFER TO ORD. i
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence of the ta.
graining;
is Permit. MECH.CONT. LIC.NO. MECH.
7x TOTAL TOTAL to
Signatureof Applicant/Contractor f=_3 Date II4.
INSPECTOR COPY '