C6849r
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL-POINT PEN ONLY
BU I LDING PROJECT I DENT]FICATI ON PERMITNUMBER
aDNG APPLICATION & PERMIT
Al'tol" �` 6849
0 p 6vew e BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S L)N PLAN CHECK VALIDATION
NA LL U{fA V. ELECTRIC PERMIT FEE
a PHDN 68$Y6
co TRACTORS r 4/ UTLETS-SWITCHES-RECEP 5.00/1.00
NAM: � ��a
V17Gwv 6Uq-. 6'uo.No. Z1 {!iV LIGHTING FIXTURES 5.00/1.00
C NTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
ADO I E. (��'//�� U 2 ()
Sim 1"0.� PHONE �I6,7+ PANELS 5.00 DATE OF APPLICATION
J wRCHITECT NNMV(V SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR 1
ENGIN)ER �,.rf/1�
I'Gl. uc.rvo. SIGNS TRANS. 3.00
ARCH.oR ENG. "J ( /f4Ave SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
/ ADORES$ Y'Y W IAJ( I
.2, lAtl fV t+.S WoA ZIP 2rj� TEMP.METER OR POLE INS. 15.00
APPLICA TS a11ft�LnJ l' ct,MHVW(R 10�•, p{�. MOTORS i SEE FEE SCH. 1
13�a P(•rr..lr< IoN {'o4.el \,H .�
r4...a ".N CA 9s O4 SERVICE CHANGE 10.00 fffTTT""
°w z
F D O LICENSED CONI RACfORS DI. RATION I?.v
rt v I hereby aldrin that I am licensed under pro,istons of Chapin''! ISSUANCE DATE
a
I G t, Ic mmeneing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
PodcMions Co and m licenu is in full forep d
z z w�` Date c Chas - I` .Lic.Number_(- S Lyl- ❑ ❑ ❑
0 H Pi Dnlc ConUactor big Y'
ys BUILDING PERMIT
m w a OWNER-BUILDER DECLARATION I INFORMATION
E
0 n N 1 hereby affirm that I am exert pt from the Contractor's Lleemw MISC.- REFER TO ORD
3 u VALUATION S/FT.
HNo J Law for the&pllowing reason.(Scc.7031.5.Busincssand Professions PERMIT ISSUANCE /6.00 �`--
Code:Any city or county which requires a permit to construct,alter. }
¢ rt ¢ 0 improve,denudish,or repair any structure,prior to its iesu.nce,also ELEC.GONTR. 1_ r LIC.NO. ELEC: i4.1
O o: requires the applicant lis such permit to file a signed statement that Ate• TOTAL // PERMIT TO -
A w m u. he is licensed pursuant to the provisions of the Contractor's License 44
Law(Chapter 1)(commencing with Section 7000)of Divisiun3ofthe rq 9e:LL/7G= 6'A•c:/�-
- a Business unJ I'ro(cssions Code)or that he is exempt therefrom end QTY. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Section 7031.5 1 STORIES TYPEJeONSTR. `
a3 _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
ofnot more Than,five hundred dollars(S500).): -
❑ I.as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their wle 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:'Circ Contractor's License Law docs not apply to an owner of
properly who builds or mpoWes thereon,and who does such Work FIXTURES-PER TRAP 4.00 sa FT FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
menlsarenotintendedorofferedforsale.If,however,the budding GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or Improveruent is sold within one year of completion,tire owner- GAS-EASYSTEM OVER 4 (EA.) 1.00
builder will have thowing It,,burden of pving that he did not build or int . - . BUILDINGUSE
RES IND CON
PB Omer
prove for purpose ol'sale.). INDUSTRIALWASTE INTER. 20.00
as owner of the property,am exclusively contracting with El ❑ ❑ ❑s
�'licens d contractors to construct the project(Scc. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:*The Contractor's 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 contmetorts)licensed pursuant to
the Contractor;License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL No.
n o n'I,,m Vtempt tildeerr Sey B.&I'.C.fort iz WATER HEATER W/VENT 4.00
Owner�lT` -�'-�'` Dat WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK RRS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
or
ia hereby affirm that I have a certificate of,,msenl«�,sell-insure, ZONING
...eby of of Workers' .a...lsut ire of
consent br a m GYn ENG.SITE NO. -
copy thereof 1Sce.3800,Lab,(-I.
Policy No. ompa
O D Certi twice is I; 1`v1 FIRESPRINK ENERGY T]4
Z Z D Certi'ie c y is Ills with the city iF,peclion division.
O Applicant- MISC.- REFER TO ORD`" Y ❑ N❑ Y ❑ N❑ -
~ w PERMIT ISSUANCE 60 FLOOD ZONE A.L.U.C.
IL CF R'11 PICA'I'It OF EXEMPTION FROM WORK Ii RS' '
LU1 COMPI:NSAfION INSURANCE PLG.CONTE. LIC NO.
d PLG. Y❑ N❑ V❑ No
O CI'his section need not be completed if the permit is for one TOTAL
D Z hundred d.11...($100)or less.)
U O 1 certify that in the performance of the work I'or which this per- OTY- MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- out is issued-I shall not employ any person in any amone so as Io
become subject to the Workers'Compensation Laws of California.
O w Date-Applicant BUILDING
CL 11 ALTER OR ADD TO MECH. 4.00
} W NO'1'I CE'10 APPLICANT: 11.after m.king this Certificate of V.-
F Z emplion,you should become subject to the Worker;Cmupensat ion APPLIANCE 4.00 PLAN CHECK
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 10MCF.M.) 3.00 ,0
CONS'T'RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000CEM.) 5.00 SEISMIC FEE
I hereby .fli. that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the porfonn.nce of the work t0T which this Permit is issued(Scc. MICROFILM
3097.Civ.C.). HEATING UNIT/(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100000 BTU
, . . .)7.
Lender's Address 50 ELECTRIC
Icertify that l have read this application and.stale that the above VENTILATION FAN (SINGLE) 3.00
infornation is correct. I agree to comply with all city and county PLUMBING
r urdin.nces and slate laws relating to building construction, and BOILER-ODMP(3 H.P.or 100,000 B.T.U.) 4.0,0
hereby'uuthurize representatives of this city m enter upon the BOILER-COMP IOVBr 100,000 BTUI SEE FEE SCH. MECHANICAL �1
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, costo cin equcnces ofhthe PERMIT ISSUANCE f3.00 / !ha CONST.TAX
may in any w y accrue against said City i
gramin oft is rmiL MECH.CONT. UC.NO. MECH. / ,
TOTAL./ V
/ /v TOTAL
Signature of pp cant/ n.actor ale ydt��
NSPECTOR COPY