6261 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
2073
�7 V19(l /�4N BUILDING=ELECTRICAL-PLUMBING—MECHANICAL 6261
OWNEN9 (/ - PLAN CHECK VALIDATION
AME - PHONE QTV. ELECTRIC PERMIT FEE
ta Cow jat�r
NAMERAcaoR's Ur C UTLETS-SWITCHES-RECEP 5.00/1.00
'ua NO, 13311 LIGHTING FIXTURES 5.00/1.00
CON THACTOR5 APPLIANCES-RESIDENTIAL,* - 4.00
' 'AooREss 30 S• 544� C!' � _ -
I 9 y
OJ' PHO. �7L PANELS 5.00 DATE OF APPLICATION
ARCHIT 'TSIGNS - 600 PLAN CHECK FEE P.C.NO.
OR
ENGINEER — SQ 64�
Llc,No. SIGNS TRANS. 7.00
ARCH.o.ENG. - SPECIAL CIRCUIT 5.00 PERMIT VALIDATION'
ADDRESS
nv TEMP.METER OR POLE INS. 15.00
. -
"PLICANT s MOTORS SEE FEE SCH. -
ADDRESS
. SERVICE CHANGE 10.00
91'17,
0 0 0 LICENSED CONTRACTORS DECLARATION
¢ U w 1 hereby affirm Olat I am ferried under provisions of Chapter 9 ISSUANCE DATE
(conlmencing.with Section 7000)of Division 3 of the Business and
2 Professions Code and license is in full fmc�e�adL fjoSL - BL ELECT. PLG. MECH.
!0 o'y— Data Class _Lie.Numbcr_LS_/.L�❑ ❑ ❑
g m F w - Uutc�O�� ' Contmilor_$ ffC C'
a Y f�', p ry
1lJD1J�1GPERMIT.
¢ ¢ w.4 .OWNER-BUILDER DECLARATION INPOfiMATION•
R
;LL N I hereby uf1-Irm that I am ixempt from the Conlructor's License
MISC.— REFER TO ORD
a,w m e law for the following maven.(Sec.7031.5.Buainessand Professions PERMIT ISSUANCE ATION $/FT.
Code:Any city nr county which oa,.masa permit toc.mameL alter,
6.00
re ra Q Q unprove,demolish,or repair ally Structure,prior to Its issuance,also ELEC.CONTR. ".LIC.NO. ELEC.
DLL . rquiln the apphcanlfor such permit to 5lca vgneJstalcmrnithel TOTAL E IT O
w$ he is IiecBsN pursuant to the provisions of the Conloctor i License C) O it v
rii, Law(Chapter 9(commencing with Section 700()of Division3ofthe r
4 Business and Professions Code)or That he is exempt therefrom and QTY. PLUMBING PERMIT FEE
It =$ ilia basis for lire alleged exemption.Any violation of Section 7031,5
TORIF YPECONSTR.
by any more than Five permit dojlum(he0).): ant toecivil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more Then five hundred Dollars(5500).):
❑ I;es ownerof the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their ole compensation,will do the work,and tire structure is not -
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,HOOF,AREA,COND. 4.00
Cddci The Contractor's License Law does not apply to an owner of
property who.builds or improves Ihemon,and who docs such work FIXTURES-PER TRAP 4.00 so.FT.FLOOR AREA TOTAL ACREAGE
himself of through his own employees,provided that such improve-
Trends are not intended or offered for sale.If,lILwa,,r,the building GAS-EA.SYSTEM-1 INC.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 have the burden of proving(hat he did not build or im- RES IND C PB onto
prove for purpose of vle.l. INDUSTRIAL WASTE INTER. 20.00
OI,as owner of the pmpan ,a exclusively contracting with 1:1 El ❑ ❑
- licensed contractors to construct the project ISec.7044,Business LAWN SPR INKLERS+1 INC 5 V.8. 5.00 ASSESSqRSPARCEL NO.
and Professions Code:The Contractor's License Low dols 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 comtmctoHv)licensed pursuant In
the Contractor's Liana Law. SEWER-SANITARY-STORM EA.200ft/B.DO TRACT NO. PARCEL NO.
❑ lam exempt under See ,B.&P.C.for This WATER HEATER W/VENT,
r u.wu 4'00
Owner ]rate WATER SYSTEM '4.00 ACC.DATEACC.FILE—NO.
WORK I!RS'COMPENSAI'ION DI:ClA RAT ION WATER TREATING EQUIP. 4.00
/ I hereby atfinB that I have o ccrti0cate of curism-1to self-inuve ZONING ENG.SITE NO.
atX\ or a certificate of Workers'Compcmamwrtif
tion Insuncu,Or ed
copy thereppf��ISec.38pp laab�.1. /G��
PulicY NaFGfI��'dI((pany Qo f < .xrf -
Q ❑ Certifed copy ishereby furnis •d. FIRESPRTNK ENERGY T 24
z Z IY Certified'�coj�Y is fled'' t th• y l uo nslon.
O Applicant—r—A.•_D,_�- �L26Cds( MISC.- REFER TO ORD. Y ❑ N❑ v ❑ R❑
� r2 CER'T'IFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.D0 FLOOD ZONE A.L.U.C.
LU > •COMPENSATION INSURANCE PLG.CONTE. , "LIC.NO. PLG.
CL 0 ('This section`need not be completed if the permit is for one _ TOTAL Y❑ N❑ Y❑ N❑
::) Z hundred dollars IS 100)or less.)
U O 1 aa
lly that in the performance of ilia work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil is isned,I shall not employ any pawn in any manner So as Tu ,
U become subject to the Workers'Compenodion Lows of Califomia.
U a Dam Apphc,ot ALTER OR ADD TO MECH. 4,00 BUILDING
} ti Ntl'I'ICE '10 APPLICANT: IL after Braking this Curti irate of Ex-
F Z enrp(ion,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK R
provisions of-the labor Code, you most forthwith Comply with FEE
U such provisions or this permit shall badeemed revoked.. - AIR HANDLING UNIT(TO 10=CF.N`0 3.00
CONSTRUCTION LENDING AGENCY , AIR HANDLING UNIT(OVER 10J"CF.M.) 5.00 SEISMIC FEE,
I hereby affirm that there is a constructilin lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sea
3097,Civ.C.): HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
Lander i Add HEATING UNIT(OV ER 100,000 B.T.U.)7.50
Lenders AJdrtss ELECTRIC
1 certify that 1 have read this application and state that the above VENTILATION FAN ISINGLE) 3,00
information is correct.I agree to comply with all Litt add monlYPLUMBING
nc
ordinaes and state laws Relating to building construction, and BOILER-Ca`'p(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to anter upon the BOILER-COMP loser 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 Iubilities,judgments, cost ami expenses which . CONST:TAX
may in an
way accrue against s,'d City conseyucna of the PERMIT ISSUANCE 3.00
I. ti-9 o Thu ,J/(nitJ/�� MECH.CONT. LIC.NO. MECH,
g J y A/ � TOTAL /s
TI/ga`ns.//((��WW.<AC i{OO'y 10 Date i'- TOTAL J
S Mum of ApLAI l_
pEcant/Conhactor Date l
OFFICE COPY