6692 51P APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
r
UI LDI NG PROJECT I DENTI FICATION PERMIT NUMBER
G , APPLICATION & PERMIT ^ /�{� 9 l9�,C ,LA .MAR- BUILDING-ELECTRICAL-PLUMBING-MECHANICAL u 92$ PLAN CHECK VALIDATION QTY. ELECTRIC PERMIT FEE
asa-3oss
N,VICTORS u e ONE
CorvTRAc7oRs OUTLETS-SWITCHES-RECEP 5.00/1.00
'�GMf
Yom_ O�1✓�G 52.12.U1CCS CC.'No411ir1I0 LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'$
ADDRESS. \ h11'•VI�-� p APPLIANCES-RESIDENTIAL 4.00 _
1V\� �a.N h(„�P-BONE I��I'a.G4O PANELS 5.00 DATE OF APPLICATION
ARCHITECT .SIGNS 6.00 PLAN CHECK FEE' P.C.NO.
OR
ENGINEER - "
" 'uc.No. SIGNS TRANS. 3.00
ARCH.OR ENG. t SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
'ZIP EMP. METER OR POLE INS. 15.00
'APPLICANT SMOTORS SEE FEE SCH. L[��
ADDRESS GGGVVV
Lti V"Arz- SERVICE CHANGE 10.00
o o LICENSED CONTRACT(3)RS DECLARATION -
u U 1 hereby affirm that I am ficenxd under provisions Chapter 9 ISSUANCE DATE
yap (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
R �.z Professions Cy de, d nsy license is in full fore and effin . Z
z O m - License ClaA3�. Lic.Number
0 F [)are ] -�_ Contractor _
to t"_ )cam BUILDING PERMIT
s a, w OWNER-BUILDER DECLARATION INFORMATION
a.w 3 .LL yI hereby infirm Out I am exempt from the Contractor's License MISC.- REFER TO ORD
VALUATION $/FT.
u0a Law for the following reason (Sec.7031.5,Business and Professions PERMIT ISSUANCE
� - -1 Code:Any city or county which requires a permit to construct,alter, 6.00
o,Q 2O improve,demolish,or repair any structure,prior l0 its issuance,also ELEC.CONTR. LIC.NO. ELEC.
aey
D u requires the applicant for such permit to rile a signed statement that TOTAL PERMIT TO
whe is licensed 9(cou i en the provisions of the Contractor's vision 3 License p
F z i
Law(Chapter 9lcoinmcncing wish Section 700Il)oC Division Sof the �ts-Q-Q O'•�-
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
F o the basis for the alleged exemption.Any violation of Section 7031.5
STORIES TYPE CONSTR.
a ; m by any applicant for a permit subjects the applicant Lou civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(5500).).
❑ 1!as owner of the property,or my"employees with wages as BACK FLOW PROTECT.DEVICE 2.00 DCC.GROUP 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. 4.00
Code:;The Contractor License Law docs not apply to an owner of ,
property who hnBds or impoots thereon,and who does such work FIXTURES-PER TRAP 4.00 s0.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedoroffered for sale.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner-
A/ GAS-EASYSTEM-OVER 4 IEA.)' 1.00 BUILDING USE
ibuilder will have the burden of proving that he did not build or im- .- - RES IND CON PB One,
n
prove far purpose of sale.).f INDUSTRIAL WASTE INTER. 20.00 El El -E:1 ❑ ❑
❑ I,as owner of the properly,a exchnivelYpontracting'with
licensed contractors to construct the project(See.7044,Business LAWN SPRINKLERS-1 INC 5 V.B- 5.00 ASSESSORS PARCEL NO.
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 -
contracts for such pruicets with a coutmctodo licensed parsuam to
- ' the Contractor's.License Law. SEWER-SANITARY-STORM EA'.200ft/8.00 TRACT NO. ..PARCEL NO.
❑ I at,,exempt un der Scc. - ,BAP.C.for Illi, WATER HEATER W/VENT 4.00
reason
Owner Dale WATER SYSTEM- 4.00qcc.DATE ACC.FILE NO.
WORK ERS'COMPFNSA'I'ION DECLARATION- WATER TREATING EQUIP. 4-00
I hereby affum•thm 1 have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insuram,,or a certified
copy theNi ec.3800Lab.C.). t1C%%C(L %
Ib0 No..L�S2$,�f re ,Dmni,h5�--Ewe} '
❑ Cetlilicd copy n hereroTy furnished.' ` FIRE SPR INK. ENERGY T"T4
Z Z Certif�I c91�v filed wuh.1the'city inspection division.
. MISC.- REFER TO ORD.
O AOplicant_[`-'�\ u���`'p'�. Y ❑ N❑ V-❑ N❑
Mw 1 ' P r+� PERMIT ISSUANCE 6.00 FLOOD ZONE "AL.uc.
LU lr - , CIiICfIP CAI' PE E I ION INS FROM WORK
,a 0 need not
be completed
if NCE PLG.CONTR. LIC.NO. PLG. . . Y❑ N❑ „ V❑ N❑
(This section need not be completed if the permit is for one TOTAL
Z hundred dollars(S 100)or less I
U O I certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F. mit is issued,I shall not employ any person in any mannerso as trr
Ow become subject to the Workers Compensation Laws of California. BUILDING
Date Applicant ALTER OR ADD TOMECH. 4.00 J�O•J�
} yNOTICIi 'f0 APPLICANT: If,alter making this Certificate of Ex-
Z enlption,youshould become subject to the Workers'Compensation APPLIANCE- 4-00 PLAN.CHECK
provisions of the Labor Code, you most forthwith comply with - FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
11 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE j
'i hereby alf irm,ihal there is a construction lending agency lou EXHAUST HOOD(WITH DUCT) 2.00
Lite pertiumance of the work lou which this permit is issued(See. MICROFILM-
3097,
ICROFILM-3097.CN.C.). HEATING UNIT(TO 100,000 B.T:U.) 4.00 "
-
Lender'sName HEATING UNIT(OVER 100,000 B-T.U.)7.50 ELECTRIC
Lender's Address
I certify that I havereud this application and state That the above VENTILATION FAN (SINGLE) 3.00
information is econcci l agrcc to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP lover tpp UOO BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
i(We) agrcc to save, indemnify and keep harmless' Ilse City of MISC.- REFER TO Of
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
gr s - g thus perm.I. MECH.CONT. LIC.NO. MECH.
t1.1t i S _ TOTAL TOTAL S L '00
Signal re of IiipplicaratiCiprifinictor rate I -
OFFICE COPY,,