3857 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY '
BUI LDING PROJECT I DENTI FICATION I •PERMIT NUMBER
BUILDING �c«.L -Q i APPLICATION & PERMIT
ADDRESS, (BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 3857
_ _ - ---- ______
DRONER S - PLAN CHECK VALIDATION
Name '
26y l J
:17Y. ELECTRIC PERMIT FEE
�EJ-i,Pfd�IGEz?va
CON
NAmE TRACTOR A OUTLETS-SWITCHES-RECEP 5.00/1.00 /yC
++°:iY•'f ��/f� ��(l� t �f LIC.NG.� g9� �if LIGHTING FIXTURES 5.00/1.00 ACTOR' -
S
ADDRESS
ADDRESS J� C 1h APPLIANCES-RESIDENTIAL 4.00
PHONE 7&49�924 I PANELS 5.00 DATE OF APPLICATION
ARCH;fECT - - PLAN CHECK FEE P F NO.
OR .t SIGNS p0�6.00
ENGINEER �7/✓D 117/ /y '/i�/ (SIGNS TRANS. 3.00
by tic ND �f
ARCH OR ENG r - 1 PERMIT VALIDATION
ADORES ��>> A//''�/�q SPECIALCIRCUIT MAY � ']
A/.11 zip/?A60 (TEMP.METER OR POLE INS. 15.00 /f�y
o i
APPLICANT'S • IMOTORS rItjswm*IPPhb1 / JT
ADDRESS, � J kbS-S, .4./ ISERVI CECHANGE 10.001 i/�/��
0 O �c1 3�
F o o LICENSED CON I'RACTURS DECLARATION I� ,
rt u w I hereby aflinn,that 1 ;tin licensed under Provisions of Chapter') 1 _ 1 ISSUANCE DATE
y G (commencing with ¢lion"!000)of Div ls,on 3 of the Business anti BLDG. ELECT. PLO MECH
r-w i Pmfes ions ode, Ill Icense Is In full l yy `�ftyjyyyt I+ -
a x Lmensvi Lm Rumher �9 - 11 ®`
rn Dam Contracmr- 5151
w WNI:R-BUILDER DECLARATION _ II BUILDING PETMW
°A " ' IM ISC.- REFER TO ORD 1 - INF RMATION
X g A I hereby Affirm that 1 am exempt from the Contractors License
u o 4 Law for the following reawn.(Sec 703 1.5,BuHnes,and Profession, VAwAT p�
E - a PERMIT ISSUANCE 6.00 16 I- J
f � > f Code Any city county which requvesapenmt to p JS•^06
Is, Sc R D Improve,demolish,or repair any structure,prior to its issuance,also ELEC CONTH LIC.NO, ELEC - 9 J�$� 1"46 3S-06
a m m ac requires the applicant for such permit to file a signet]smlement that TOTAL P
he¢licensed pursuant to the provisions of the Contractor's License /nQ ion i o Bathtub,andrProfessions hCo le)or shaft he is exemptytherefrom and CITY.( PLUMBING PERMIT FEE
r$ the basis for the alleged exemption.Any violation of Section 7031 5 STORIES TYPE CONSTR.
a ; _ by any applicant for a permht subDut,the applicant Io,,civil penally ./,.
of not more than foe hundred do[[,,(S500L). ALTER-DRAIN&VENT-WATERIEA.) 4.00 S h4-q
I p2
A1
❑ I,as owner of the property,Dr my employees will,wages;, BACK F LOW PROTECT DEVICE 200 /a ^
their sole compensation,will do the work,and th is . . BCC.GROUP RES.UNITS
structure not _ p
intended or offered for sale (Sec. 7044. Business and Professions " DRAINS`FLOOR�ROOF,AREA,COND. 4.001 /A-3, -
Code'The Contractor's License Law does not apply to an owner of __ s
/+r•' property who builds or improves thereon,and who does such work )FIXTURES PER TRAP 4.00 — so FT ELOOR AREA TOTAL ACREAGE
!its r hints are not intended own employees,
fors,pe.If, ever,the build, GA5-EA.SYSTEM-1 IRPAI1TLETS 4,001 �Q
meals ore not t is win or offered for side.If,however,tie budding
'l 'H Improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.001 RuILOfNG USE
9 bolder will have the burden of proving that he,dl i nut hudd or rn-
�"fG;,�r prove for purpose,of sale! INDUSTRIALW� INTE�t. 19 4 20,00 HES IND coN PB once,
❑ 1,as owner of lire Properly,am erclus,vely contracting with I El El El El
licensed con"mclors to construct the protect(See. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.001 ASSESSORS PARCEL NO ,
and Professions Code'The Contractor's License Law does not apply
to an owner of property,who builds or unproves thereon.and who! LAWN SPRINKLE6RyC*IMPQ8AIQ 1.001 ' 3 `fog —���-005`
contracts for such proje cis m
s with a tttractots)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY,-STORM EA.200ft/8.001 Cf � � TRACT NO PARCEL NO
❑ loin exempt under Sec •,B.kPC for this
reason l )WATER HEATER W/VENT • 4.001
Oat- I Owner 1 WATER SYSTEM 4.001 4 ACC DATE ACC.F'LE NO .
WORKERS'CO.M PENSA'I ION DECI-ARATION WATER.TREATINGEQUIP. 4.001 I .
I liereby atf,rm Thal I base a certficate of consent to sell.insure.
ors certificate f Workers'Conhpensation Insurance,or a ecrtified I I ZONING ENG.SITE N0.
copy ther16,' c jAOQLab C,l.(� � S/�,J .//t2G r
Q 10 Certified cajrin Is hcrchdf wHI cth I • 1 FIRE SPRINK' ENERGYT.24
'Z LD ❑ ant p (led wN he ty Ire e n do lswn
O Applicant G�yjt• MISC.- REFER TO ORD. y� N ] v � N]
~ ZFI:017E EM 1 PERMIT ISSUANCE 6.00
ir N CIi R'I'IF CAfI:fill'I CEh1 ION PItOA1 WURKfl ti' FLOOD ZONE A L.U.C.
W J COMPFNSATION IN URANCE (PLO CONTR LIC.NO. PLO /
C Cl fTh s section need not be completed if the pennt I, for one I TOTAL W Q y N v N
Z) 2 hundred dollars IS 100)or less.! + ,
U O I cerGly that In the'performance of the work fur which this per- OTY. MECHANICAL PERMIT FEE I- FEE SUMMARY
LL H Hillis Issued,I shall not employ any person in any manner w a,to
U become subjeel to the Workers'Compensation Laws of C;dd'orma
y Date Applicant ALTER OR ADD TO MECH. 4.001 t BUILDING
} w N'OT'ICE.TO APPLICANT' If,After reeking this Cenitictte of Ir-
� 2 'emptlon,you should become subject to the Workers'Compensutunl - APPLIANCE 4.001 I PLANCHECK
-
provisions of the Labor Code, you must forthwith comply with
such FEE�p,�
U ch provisions or Ibis permit shall be d revoked deemed roked AIR HANDLING UNIT(TO kWU.M.) 3.001 ,9 t
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10SWC.F..M.) 5.001 SEISMIC FEE /0 a8
Thereby affirm that there is a construction lending agency Ion I EXHAUST HOOD(p AFY Df16fi) i9642.00 -2
file perform arcs, of the work for which In,pernut is Ylued(Sec MICROFILM
3097,CIv C.) / HEATING UNIT (TO 100,000 B.T.U.) 4.001
Lenders Ndme H EATI NG UN IT(O\��s�s�01, .RIP7.50 Sa
Lenders Address vQ^lI .'I ELECTRIC 93
I terrify that!!
lave read this application and state that the above! �fi VENTILATION FAN (SINGLE) 3.001 ay ,I
'information Is correct I agree to comply wall all city and cutility I PLUMBING r(i�
ordm:mces and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.001 I +
hereby authoFve representatives of this city m enter upon the I MECHANICAL
those-mentioned property for inspection purpose,. BOILER-COMP (Over 100,000 BTU)SEE FEE$DH. J(P
Zlsaiot�- (we) agree to stile, uWentnlfy and keep harmless the City of I MISC.- REFER TO ORD.1 I
Cupertino against liabilities,judgments, costs and expenses exhmn .�i CONST.TAX
m
ay any way over,c.a. Hat sald City tit co lsequunc(ee if the •PERMIT ISSUANCE 3.0013
g� lingo( ills perms/ 1 al A MECH.CONT LIC N0. MECH If ��� Oy�
TOTAL TOTAL
at ofA cant ontractor
OFFICE COPY