7277 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 7277
ADOREss
IOa Y —7 D21 v 2 BUILDING —ELECTRICAL—PLUMBING —MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
AcroR's
NAME UTLETS-SWITCHES-RECEP 5.00/1.00
NAME
LIC.NO. LIGHTING FIXTURES 5.00/1.00
CONTRACTORS
PP
CONTRACTORS 4,00
ADDRESS
PHONE PANELS 5.00 DATE OF APPLICATION
' R
CHNrtEC
. . PLAN CHECK P.C.NO.
OR SIGNS 6.00
ENGIEERLTV `V ucNo
SIGNS TRANS. 3.00
ARCH.OR ENG, PERMIT LI�ION
ADDRESS SPECIAL CIRCUIT 5.00
C/O t Sti Ago n 2Cl. SRN ZR efs EMP. METER OR POLE INS. 15.00 n /1�I(
pDDRESST's MOTORS SEE FEE SCH.
DOREss
SERVICE CHANGE 10.00 a
'00 LICENSED CON']'RACE ORS DECLARATION
¢o ci 1 hereby affirm that I not licensed under Provisions if Chapter 0 ISSUANCE DATE
HQ w (commencing with Section 7000)of Division 3 of the Business ants BLDG. ELE T PLG. MECH.
H m z Professions Code.and my license is in full force and effect. ❑ ❑
z o m — License Class Lic.Number
g I w Date Contractor
a is
BUILDINGBUILDING PERMIT
c, ¢ a a OWNI;R-IIUILDIER DECLARATION
w 3 a r I hereby affirm that I am exempt from the Contractor's License
M ISC.— REFER TO ORD INFORMATION
c LLoj Law furthe following reason. 7031.5,Businessandl'rofessions PERMIT ISSUANCE VALUATION S/FT.
H _ 6.00
Code:Any city or county which requiresa permit toc'onstruct.niter,
¢ ¢ ¢ o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
D ¢ requires the applicant for such Permit to file a signed statement that TOTA rPERMIT TO
w u he is licensed pursuant to the provisions.1 the Contractor's License _
F z r Law(Chapter 9(commencing with Section 7000)of Division 3 of the '
— ec Rosiness Dad Professions Code)or thal he is exempt therefrom and QTY. PLUMBING PERMIT FEE•
¢ ro the bm'isl'otthe alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n3 �2 by tiny applicant lbru peroth subjectsteupplicanl tuacivilpalally ALTER-DRAIN&VENT-WATER IEA.) 400
of m moa thmr frvc hundred dollars(5500).):
I,as owner of the Property,or my employees with wages as ACK FLOW PROTECT. DEVICE 2.00 UCC.GROUP RES.UNITS
tit-r sole compcnsut inn,will Jo the work,and fire stmcture is nor i
intended or offered for sale(Scc- 7044, If uxinuss:cod Podessions DRAINS-FLOOR,ROOF,AR EA,CON D. 4.00 1
Code:'fire Con rractur,License Law docs not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 SO.FT.FLOORAREA TOTALACREAGE
h imselfre throughhis owncelplo fors, le.If,h evtsuch intProvo-
octets are not intended or ufl'cred lin sale.If,however,the building GAS-EA.SYSTEM-1 INC.4OUTLETS 4.00
or fel Provmnent is sold within rnte ycur of completion,the ,.net. GAS EASYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will hove rhe burden 4proving that he - .did not build or int- RES IND PB Omer
prove 1,aso nee of soleal. INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑
❑ d as owner of the property,am projeciv Se contracting wish
and
contractors to a construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSO PARCEL NO.
and Professions Codc:The Con build o License Law docs not apply
to tr owner of property who builds tr improvli Utsed pursuant
who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts raps for such projects with a mntruclorts)licensed punuunt to
the Contructori Limns Luw. I SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lamexemptunder See ,RAP.C.for this WATER HEATER W/VENT 4.00
reason
Owner Dote WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORK ERS'COM PENSA1[ON DECLARATION IWATER,TREATING EQUIP. 4.00
1 hereby affirm that I have a ccrtilicatcofmnsent toself-insure, ZONING ENG.SITE NO.
i a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3804 Lah,C.). '
Policy No. Company
O ❑ Certilicd copy is hereby famished. FIRE SPRINK ENERGY T24
z p Applicant Cer
OlicCer ified copy is filed with the city inspection division. MISC,- REFER TO ORD. V N y ❑ N E]❑ ❑
FN PERMIT ISSUANCE 6-00 FLOOD ZONE A.L.U.C.
2 CIiR"fI1lGOIi OP.AIION INS FROM WORKIiRS'
UJ > CO S11'ENSAI'ION INSIIRANCC PLG.CONTR. LIC.NO. PLG. V❑ N❑ Y❑ N❑
CL Z CL 0 (Phis section evil not be completed it the permit Is for one TOTAL
hundred dollars IS 100)or less.) ,
U O 1 certify than in the performance of�he work for which this per- QTY. MECHANICAL PERMIT FEE a FEE SUMMARY
LL F- snit is izsucd, 1 shall not employ any prow n in any mann,,so as to 1
U become object to the Workers'Com pcn alio,laws of California.
U n Late
d AA�k —Applicunlfstw •�'t) ALTER OR ADD TO MECH. 4-00 BUILDING
} N NU77,;T AI'1'LICANT: It',alter making this Certificate of Cs- ,
F Z emprion,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of 0m Labor Codc, you must forthwith comply with FEE
U� such,p,ovfsions or cis permit shall be deented revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 3,00
' CONSTRUCTION LFNDING AGENCY AIR HANDLING UNIT(OVER IOAWC.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a "Instruction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name RSt\ Cf—T— APAQ' «^ HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Addmu _f' 41 A-1 3.6 i- 411 ••
. .. ELECTRIC
I ccnily that l laveread this application and State that Out above VENTILATION FAN (SINGLE) 3.00
information is correct. 1 agree to comply with all city and county PLUMBING
onlinances and state Paws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
bcreby authorize representatives of mn tire this city to enter upon BOILER-COMP (Over 100,000 BTU)SEE FEESCH. MECHANICAL
above-Iocntioned property for inspection purposes.
(We)�uFree to save, indemnify and keep hamilux the Ciry of MISC.- REFER TO ORD,
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may inion a uccru• PERMIT ISSUANCE 300
Y Y way gains d lY t consequenn of Ibc
gmnli ng o `mut.��/ MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL .
'Signature of Applicant/Conlmctor Law
INSPECTOR COPY 4 r'I