09725 APPLICANT. TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI` I. ^ PERMIT NUMBER
BUILOIN oL APPLICATION &,PER /�
uooREss T09725 9 7 /'5
BR �77 qc 40" BUILDING-ELECTRICAL-PLUMBING=MECHANICAL a1 L.I
OWNER'S p/fERT� /TIRE-S O ' '. :PLAN CHECK VALIDATION
"ante - QTV. ELECTRIC PERMIT FEE r
P E S/f l `a!I 323-52.
crDRs
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00 "
NAME
uc.No I LIGHTING FIXTURES ? 10:00/1.00
-,4CONTRACTOR'S �• /• /q PPLIANCES-RESIDENTIAL 4.00
AD°RESs (�SJ ��RMOSgR �✓ y' p
MEiUIO ?'FSR 51(d� z Sz2l PANELS 10.00 DATE OF APPLICATION
ARCHITECTPAN ELSIOV ER 200'AMP17 20.00 PLAN CHECK FEE _ P.G NO.. _
�[ °R
.ENGINEER 70H.V ffERM/ yA/SSO4F 'x
LIC,NO, SIGNS TRANS. - '3.00
noo OR EN •01O IV.S7' •q SPECIAL CIRCUIT - 5.00 - PERMIT yq�rypN '
?/g(.0 174ro C/7• z,P/. _V EMP.METER,OR POLE INS. 20.00 lV'
...HE Nr's ESS' pER/Y�S/� �✓�y ' MOTORS - : " � '. SEE FEE SCH.'
aooREas V
Mia ?',g,P cog, 9,yo,25 SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION. TEMP.POLE 30.00p1yEr 01 CUpQI LIn�
a u I hereby affirm that I im licensed'under provisions of Chapter 9 - - ISSUANCE DATE
3 i C-came with Section 7000)of Division 3 of the Business and - BL ELE T. PLG. 'MECH.
H y i Professions Code,a 1 my license is in full force t effe
z o w - License Class_ Lic.Number - `
0 w- Dare 2 '+w i9;g Contractor -
a xT� BUILDING PERMIT
¢ ¢,4 OWNER-BUILDER DECLARATION .••
E: o a u - - -A :INFORMATION
w 3¢ w 1 hereby affiralfhat I am exempt from the Contractor's License MISC.- REFER TO ORD
._ o st Law for the following reason(Sec.703).5,Beertessand Professions PERMIT ISSUANCE ? 10.00 - VALUATION $/FT.
- w Code:Any city or county which requires a permit to construct;alter, -
improve,demolish,or repair any Structure,prior to its issuance,also ELEC.CONTR. LIC.NO.' _,r L
K ¢ 4 O P P' Y p ELEC. /31
n
O ¢ requires the applicant for ILIA permit to file a signed statement that , - - p TOTAL/ V PERMIT TO
w ¢. he is licensed pursuant totheing provisions of the Contractors 3 of
he '} _
r z i Business
(Chapterand
Professions
Cod )withSectionis 00)exempt
therefrom
o of the -
4 Business and Professions Code)or that he is exempt therefrom and QTY. - -PLUMBING PERMIT l FEE
'
¢ o the basis fonlhe alleged exemption.Any violation of Section 7031.5 t STORIESTYPE CONSTR.
aim byany applicant for apermit subjects the applicant toacivil penalty
ALTER-DRAIN&VENT-WATER (EA.) 5.00 6� %
of not more than five hundred dollars($500).): _ f, •K 1 _
❑ I,as owner of the property,or any employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP n RES.UNITS
their sole compensation;will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions • DRAINS-FLOOR,ROOF,AREA;COND. 5.00 r'
Code:The Contractor's License Law does not apply lin an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP -SG.FT.FLOOR AREA TO L ACREAGE
himself or through.his awn employees,provided that such improve-
mentsare not intended orn0'eyed for sale.If,however,the building. GAS EA.SYSTEM-I INCA OUTLETS 6.00
orimprovement is sold within one year of completion,the owner-,
€ builder will have the burden of proving that he did notbuild or im. GAS-EA.SYSTEM
OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 IND CON PB Other
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ .•❑ ❑
licensed contractors to construct the project(Sec:'7044,Business LAWN SPRINKLERS-'1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply '
to an owner of property whobuildsor improves thereon,and who LAWN SPRINKLERS-OVER$IEA.) 1.00
contracts for such projects with a conlmctods)licensed Pursuant to -'
the Contractor's License Law. . s SEWER:SANITARY-STORM EA.200ft/10.00 TRACT No. PARCEL NO.
'k
- -
❑- lam exempt hinder Sec. -,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILENO.
' WORKFRS'COMPENSATION D17CLARATION WATER TREATING EQUIP. 5.00 ,
1 hereby affirm that I'have a certificate of consent to self-in,me,
or a certificate of Workers'Compensation Insurance,or'a certified ENG.SITE NO.
I
copy therf( [$p{Qp.0,Lab.C. pp
Policy Nn `FompunY�/"`LL'�Idif/r� _ -
0 IV Certified copy is hereby famished ' - FIRESPRINK ENERGY T 24
Z.Z ❑ Certified o y is filed with the city inspection division. -
FO Applicantt,.�pQ, 'r MISC.- '.r: REFER TO ORD. Y❑ N❑ Y ❑ N❑
a
va -PERMIT ISSUANCE 10.00
LU - CERTI FICCOM COMPENSATION
INS FROM WORKERS' FLOOD ZONE A.L.U,e.'
LU 1 O _ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. _�/n1
Z (This wetion need not be completed if the permit Is for one TOTAL ,W ❑ N❑ ❑ N❑
hundred dollars 1$100)or Iem.) -
U O I certify that'ib the performance ofthe work for which this per-,iOTV'. MECHANICAL PERMIT FEE ' FEE SUMMARY
mil is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers Compensation Laws of,California.
p• Date Applicant ALTER OR ADDTO MECH., °5.00 BUILDING
} m NOTICE 10 APPLICANT: If,after making this Certificate of Ex
I..--'Z emption,you should become subject to the Workers'Compensation APPLIANCE - 5.00 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'10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY - AIR HANDLING UNIT(OVER 10=C.P,M.) 6.00 SEISMIC FEE 0
Thereby affirm that their, is a construction lending agency for ,' EXHAUST HOOD (WITH DUCT) 5.00 ' /
the performance'of the work for which this permit is issued(Sec. - MICROFILM
3097,Civ.C.). 'VQ 4F1 CONJ�RUC� D HEATING UNIVTO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000B.T.U. .50
Lenders Addres' )8ELECTRIC 2 0� '
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) - 4.00
to random pis correct.1 agree to comply with all'city and county' PLUMBING AM
ordinances and state laws relating to*building construction;and BOILER='COMP(3H.P.Or 100,000 B.T.U.) 6.00
1 hereby authorize representatives ec this city es elver.upon'the BOILER-COMP(Over 100,000 BTU)SEE FEE SOH. MECHANICAL
above-mentioned property for insp of this
purposes,tis. _
(Waj agree to save, indent ' "kcoP harmless the City of MISC.- REFER TO Ofl D: •^n
Cupertino against li. in gments, costs and xponse.which - CONST.TAX (/V
may in any accrue st-said City in asequence ofIthe PERMIT ISSUANCE 10.00 116,
gtanti. his "" MECH.CONT. - LIC.NO. MECH.
TOTA . TOTAL,
40at pplicant/Contractor' Date. -
' 4 OFFICE COPY