11327 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ApPRE
J� BUILDING —ELECTRICAL—PLUMBING—MECHANICAL 11327
OWNS R'a PLAN CHECK VALIDATION
ti
NAME .q. Si'X �w:(?rie :�Sf.:
/T �y6
QTY:•1 �.',;,;T�`:y ELECTRIC PERMIT.'.,' ---" FEE
`•/�••-
NAME O
J NAME UTLETS-SWITCHES•RECEP 10.00/1,001
UC NO LIGHTING FIXTURES 10.00/1.001
CONTO
�ADDRESSTORS APPLIANCES-RESIDENTIAL 4.00
PHONE I PANELS 10.00 DATE OF APPLICATION
ARCHRECi - - - - - - - - - - - - - - 0 PLAN CHECK FEE V.C.NO.
oR I PANELS (OVER 200 AMP) 20.00
ENGINEER - - — — - - - -
LIC no. _ _ SIGNS TRANS. 3.00
ADDRESS END' SPECIAL CIRCUIT 5,00•i/ ^^ PERMIT VALIDATION
zlv �� TEMP.METER OR POLE INS. 20.0011
APPLICANT'S
ADDRESS _ MOTORS SEE FEE SCH.II��,, 11
Iy/ (SERVICE CHANGE 20.00�cQ
LICENSED CONTRACTORS DECLARATION
<u w 1 hereby affirm that I am licensed under provisions of Chapter 9 ' ISSUANCE DATE
w y n (commencmg with Section 7000)of Division 3 of the Business ar: BLDG ELECT PLG. MECH.
N i Professions Code,and my license is in full force and effect. 5(6
ON H C License Class Lin.Number
r w Dale Contractor
e¢ a OWNER-BUILDER DECLARATION VVVV B LDI G P @RMIT'°^f^
fMISC.— REFER TO ORD INFORMATION-
w; w 1 hereby affnm that I am exempt from the Contractor's License I p
B. O a law for the following reason (Sec 703 I.S.Buscessand Professions VALOATION §/FT.
F w r f Code: e,dKovy or county it any structure.permit prior to is issuance,alter,
ERMIT ISSUANCE 10.00 Q� 1
z a < p improve,demolish,or repair any structure,prior n its issuance,also ELEC.CONTR LIC NO. ELEC. �~
O LL requires the applicant for such permit to file a sinned statement that I I TOTAL = 1E MIT TO
' su°m he is licensed pursuant to the provisions of the Contractor's License _ _ ��
H t Law(Chapter 9(commenemgwsth Section 1000)ofD.visio.3a fine ;''kA•1`Lr.i�e''-• TB
a c Business and Professions Code)or that he is exempt therefrom and QTY:"-o y„ F',-`"t-',Ce_PL,UMBING PERMIT.-e-�, , k„Y;FEE f
i- the basis for the alleged exemption.An violation of Section 7031 5 .,.3:+--" i •. ,;.,;:..�:•.'^'r 1 74,z,r 1'1-y^
w °m 6 P Y A. - _ fz:i4 ST }.S TYPE CONSTq.
by applicant fora permit dollan($50PPhcant too civil penalty gLTER•DRAIN& VENT•WATER
.f ine more than five hundred property,o(my em' I 1
❑ Las owner of the property,or my employees with wageset 1 BACK FLOW PROTECT.DEVICE 4.001 1 OCC.GROUP RES.UNITS
/heir sole compensation,well do the work,and the sirvemre is net
intended or offered for sale (Sec. 7044, Business and Professions I DRAINS-FLOOR.ROOF,AREA,COND. 5.001 1
yp Code:The Contmctor's License Law does not apply to an owner of
=- property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 ISa FT FLOOR AREA TOTALACREAGE I ,
himself or through his own employees,provided that such improve- 1 -
meats arc not intended or offered for sale.If,howeveothe budding GAS•EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner
builder will have the burden of proving that he did not build or Ice- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 I 2sU1LOL:G USE
p for purpose ofsaie.) 11 RES ]NO CON PB omer
1,as owner of the property,am exclusively contracting with 1
INDUSTRIAL WASTE INTER. 3000 1
en d contractors to construct the protect(Sec, 7044,Business I LAWN SPR IN KLERS- 1 INC 5 V.B. 6.00 - 1 ASSESSORS PARCEL NO
nil Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon.and who 1 LAWN SPRINKLERS-OVER 5(E0.) 1.001 1
contracts for such Projects with a confraclods)licensed pursuam l.. SEWER-SANITARY-STORM EA.ZOOft 100
. 0
the Contractors License Law. 1 / 1 1 TRACT NO. PARCEL NO.
❑ lamexdeI,$ec ,B.&PC for Ibisl WATER HEATER W/VENT 6.001 1
� �'-'lyInic I WATER SYSTEM 5,00 I I ACC DATE ACC FILE NO
WORI:F-RS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00 1
1 hereby affirm that 1 have a certificate of consent to self-insure.I 1 1
of a certificate of Workers'Compensation Insurance,or a certifle� ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
❑ Certifiedcop)'Is hereby furnished _ _ _ I I FIRE SPAIN ENERGI'T1a
7 Z ❑ Certified copy is Bled with the city Inspection division -
O Applicar' I 1MISC.- REFER TO ORD. Y 11 N(] Y N�
YN
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 1000 1 FLOOD ZONE I A.L.UC
.0 > COMPENSATION INSURANCE (PLG CONTS. LIC.NO PLG
1 O (This section need not be Completed If the permit is far one I TOTAL Y N y 1] No
hundred JWIS,S 0100)or less)
I certify that to the performance of the work for which this per,I OTY1 '7, MECHANICAL PERMIT I FEE FEE SUMMARY
L, '
U Out is issued,I shall not mnploy any person In any manners.as to
become subject to the Workers'Compensation Laws of Callforma
7 y Date Applicant 1 BUILDING
Z NOTICE TO APPLICANT If,after making Ihis Certificate ALTER OR ADD TO MECH. 5.00 of Ex E
empuon,you should become sub/eel to the Workers'Compensation I APPLIANCE 5.00 PLAN CHECK
Provisions of the Labor Code, you must furthwith comply wit:. - _ FEE
such provisions or this permit shall be deemed revoked 1 AIR HANDLING UNIT lTO 10A000.F,NU 4,00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IQOOOO.EM.) 6.001 SEISMIC FEE
I hereby affirm that there is a construction lending agency for 1 EXHAUST HOOD(WITH DUCT) 5.001
the performance of the work for which this permit is issued(Sea MICROFILM
3097,Cn C.) 1 HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Adilp-
HEATING UNIT(OVER 100,000 B.T.U.19.50 I ELECTRIC
I`
1 certily this I have read thrs application and slate that the above I VENTILATION FAN (SINGLE) 4.00
fp'mahon is correct. I agree to comply with a1i oily and counlY PLUMBING
'ances and state laws relating to budding construction. and BOILER-COMP(3H.P.or 100,000 B.T.U.) 6.00
o ,y xvthonae representatives c this nly' to enter upon the BOILER-COMP IOvas 100,000 STILL,SEE FEE SCH,1 MECHANICAL
o .vey tmIh ,L, property for inspection purposes
(We) agree m save, indemnify and keep harmless the City of MISC.- REFER TO ORD. I
Cupertino against liabilities,ludginents, costs and expenses which PERMIT ISSUANCE 10,00 1 CONST.TAX
may In any way accrue against said y m Consequence of [lie I
ranting. his rg41 MECH CONT LIC,NO MECH.
TOTAL
Sigma sere 6L pp Mani/-on rector TOTAL
CFFICE COPY