18852 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
PUDDING APPLICATION & PERMIT n
ADDRESS - (J
�iIYl A�.r_,/�p,:cN p BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNERS /7LL� CCC PLAN CHECK VALIDATION
NAM �.y)f OTY. - ELECTRIC PERMIT FEE
PHONE - a
is
CONTRAC
TOR
a�sS UTLETS-SWITCHES-RECEP 10.00/1.00
px /,M ,
C , sec.No.2� LIGHTING FIXTURES 10.00/L00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00 -^Z1^Q,D
A7AtIW ,9J'Z�7 -
PHONE PANELS 10.00 DATE OF APPLICATION
RCHDECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
O
OR
ENGINEER'.
LIC,No. SIGNS TRANS. 3.00
ADDRESS eNa SPECIAL CIRCUIT 5,00 PERM - A TION
+
APPu6ART5 ZIP TEMP. METER QR POL S 20.00 � � 2 71990
AD�� MOTORS EE FEE SCH.
ADDgE /�t
SERVICE CHANG ftA 20.00 whfQQnf ee/�E��f�•µ'M.�/,/},1''—_`W.,
o ¢z. �\� Q`��
r o o. LICENSFI)CONTRACI ORS DECLARATION
< u 1 hereby affirmthat I am licensed under provisions of Chapter 9 ISSUANCE DATE
< n (commencing witliSection 70001 of Division 3 of the Business andBLDG. ELECT. PLG. MECH.
H m i Professions Code,and my license is in full force and effect. ❑ ❑
z o License Class Lic.Number
E N F Date Contractor
a m f -BUILDING PERMIT
¢ ¢ i a OWNER-BUILDER R-BUILDIiR DECLARATION - INFORMATION
ws- I hereby affirm that I am exempt from the Contractor's License MISC.— R R TO ORD
LL0< Lawforthefollowineireasoa(Sec.703L5,Busincse and Professions PERMIT ISSUAN E 10.00 VALUATION S/FT.
Cale:Any city or county which reyuiresa Not toconstmet,aller.
rt W¢ at 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
a
O u requires the applicant for such permil to file a signcd statement that TOTAL PERMIT TO
La $m he is licensed 9(comm en the provisions of the )of
Divtor s Loathe
Business
(Chapterand
Professions
Codeng )or Section is exempt
therefionrom
oof the
f E D the bais and Professions Code)or that he is exempt thcrcfrom and QTY. PLUMBING PERMIT FEE
¢ F the basis for the allege)exemption.Any violation of Section 7031.$ STORIES TYPE CONSTR.
i by anythen,applicant fora urid,cld.1latslhe0),): anUoacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than Hve hundred dollors(SS00)J: - '
0 I,as owner of the Property,or my employees with wages as BACK FLOW PROTECT'.DEVICE 4.000CC. ROUP RES.UNITS
their vole compensation,will do the work,and the sNucture is not
intended or offend for sale (Sec 7044. Business and Professions _ DRAINS-FLOOR,ROOF,AR EA,COND. 5.00 W Y1 —2
Code The Contractor's License Law does not apply to an owner of fJAL
property who builds or improvt,,thereon,and who doss such work FIXTURES-PER TRAP 5.00 SO FT.FLOOR AREA TOTAL ACREAGE
himself Or through his own employees,provided that such improve - GAS- 1-11NC.40UTLETS 6:00 mm�L arc not intended or offered for srlc.lf,however,the building _
orimprovement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 IEA) 200
builder will have the burden of proving that he did not build or int- GAS . - ., .
- BUILDING USE
prove for Purpose of sale.). INDUSTRIAL WASTE INTER. 3000 RES IND CON PB Omer
O m I,as owner of the property,aexclusively contracting wi .
th ❑ - El V ❑ ❑
licensed contractors to con0ruct the.project(See.7044.Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 _ A—WSSo PARCEL No.
and Profession,Code The Contractor',License Law docs not apply
to an Owner Of molferty who huilds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a cuntracoms)licensed pursuant to SEWER-SANITARY-STORM EA.20011/10.00
the Contractors License Law. - TRACT NO. PARCEL NO.
❑ lam exempt under Sec.—.B&P,C.for this WATER HEATER W/VENT 6.00
RJSmI
Owner Dat, WATER SYSTEM 5.00 . ACC.DATE ACG FILE No.
WORK IiRS'COM PENSATION DIiCL1RA1'ION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insun. ZONING ENG.SITE NO.
ora certificate of W rkers'Compensation Insurance,or a certified
copy the 0,Leb.C.l,
Policy N4-.e _ Company_ !v
O ❑ Certified copy ishcreby lurnis cd.
FIRE SPRINK ENERGY T-29
Fp A❑hcan C,m0 c/cpp 'is fit ed will the c m
In — s echmn division. MISC.- REFER TO ORD. V❑ N❑ V ❑ NE]
w - � �CFRI'IFICAI'E OF EXEMPTION FROM WORKERS' L0PERMIT ISSUANCE 10.00 Q7 f0020NE A.L.u.c.
LLI > COMPFNSATION INSURANCE PLG.CONTE. LIC.NO. PLG, ixA YE:] N❑ 1' E) N❑
EL 0 IThis section aced not be completed if 1110 permit is for one TOTAL
hundred dollars IS 1001 Or les.)
U O I certify that in the performance of the work for which this Per. QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL I— mit is issued,1 shall not empWy any Perwo in any manner To,as W
O w become subject to the Workers''Compensation Laws of California. BUILDING
C_ Dat° Applicant ALTER OR ADD TO MECH. 5.00
} ED NOTICE TO APPLICANT: If,alter nicking this Certifmatc of Ex- -
? umption,you should become suhiect to the kVurkeri Compensation Z APPLIANCE PQ11 P Z^ 5.00 1 Cs® PLAN CHECK
provisions of the Labor Code,you must forthwith comply with FEE
U wch provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000CF.M.) 4,00 L
CONSTRUCTION L17NDING AGENCY AIR HANDLING UNIT(OVER IO)OODC.F.M.) 6.00 SEISMIC FEE
I hereby iffml that there is it construction lending agency lot EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work liar which this permil is issued(Sec. MICROFILM '
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Fame
I Lop
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
`
1 certify that I have read this application an1
d state that the above VENTILATION FAN (SINGLE) 4.00 KL
i nlornlatim is curn¢t. I-agiec.to comply with all City and county PLUMBING /-CO
Ordinances and state laws relating to building construcliom. anti BOILER-COfaP 13 H.P.or 100,000 B.T.U.) 6.00 I
hereby authorize representatives of this city tu'enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL ,v
above mentioned property for inspection purposes. _
(We) agree to save, indemnify and keep harmless the City of MISC. (b REFER TO ORD. (Q00
Cupertino against liabilities,judgments, costs and expenses whichPERMIT ISSUANCE 1000 CONST.TAX
may in any way accrue against said City in consequence of the
anling of this ponnit. MECH.CONT. LIC.NO. MECH. r
TOr�L ^Q TOTAL
Signature of Applicant/Contractor Date C9 L� t
OFFICE COPY