8169 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ONPERMIT NUMBER
BUILDING 'APPLICATION & PERMIT
r. AooREss - _7 7'S Q / BUILDING-ELECTRICAL-PLUMBING -MECHANICAL rr ' 8169
Own s / PLAN CHECK VALIDATION
,( NAME OTY. ELECTRIC PERMIT FEE
• ' ,� ' PHONE -7 2 3759
NAMERAc Rs ' UTLETS-SWITCHES-RECEP 10.00/1.00 /0 �/U/✓ Yl
1 c� LIC.No. / / LX�LIGHTING FIXTURES 10.00/1.00 33`
CONTRAS 's '
ADDRESS APPLIANCES-RESIDENTIAL 4.00
r
PHONE f ( PANELS 10.00 DATE OF APPLICATION
OR
ARcmTw PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
_
ENGE
uc.NO. SIGNS TRANS. 3.00
RCH.INORER ENG. PERMIT VALIDATION
ADDRESS _ L SPECIAL CIRCUIT �'j5.00 it
5 � rrEMP.METER OR POLE INS. 20.00
APPLICANTMOTORS SEE FEE SCH.
POOR E55
�f- K SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARA' ON a TEMP.POLE 30.00 �/ G O f
a v U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w RL ELECT. PLG. MECH.
(commencing with Section 7000)of Division 3 of the Business and
wi Professions Code nd my Deetse is in full force and effect.
z o m - License Class Lic.Number -)
o - Date� m,act., 5 �\
4 y E �' ( Off(^ 'J BUILDING PERMIT
¢ ¢ w OWNER-BUILDER DECLARATI N INFORMATION
Aod MISS.- REFER TO ORD
w 3 LL N I hereby affrm that I am exempt from the Contractor's License VALUATION $/FT.
F LL o j Law for the following reason.(See.7031"5-Busincs<:uul 1'mfessions PERMIT ISSUANCE 10A0 r qy)
Fuse Code:Any city or county whichrequiresaperntitioconstruct,alter,
ce 2 G O improve,demolish,or repair unv structure,prior to its issuance.also ELEC.CONTR. LIC"NO. "ELEC. So (J
D LL requires the applicant for such permit to file a signed statement that TOTAL/ .N 6 PERMIT TO
e w es he is licensed pursuan Lto the provisions of the Contractor's License
Z.¢ Law(Chapter 9(commencing with Section 7000)of-Division 3 ofthe
Business and I'mfcsnons Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE V
re r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONrrFF
a3� by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not comm than five hundred doll...(5500).):
❑ 1,as owner of the property.or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00 ''/
their sole compensation,will do the work,and the structure is not T DCC.GROUP RES.UNITS
intended or offered for sale (Sec 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,to,s,provided that such improve-
orunprrenotnientienoldor withinrone year
If,however,(lie building GAS-EA.SYSTEM-11NC.40UTLET$ 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or ice RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to constinet the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 7 A$$ES$OR$PARCELND.
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 projects with a confactons)licensed pursuant to SEWER-SANITARY-STORM EA.200ftI10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ Ian)exempt undir Sec ,B.&I'.C.for tlli. WATER HEATER W/VENT 6.00
reason
Owner Dale WATER SYSTEM 5.00 "114 - ACC.DATE ACC.FILE NO.
WORKERS'COMPEN'SATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that l have a certificate of consent to self-irrmv,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(See.3800,Lab.C.)._ r� A�
Policy No. company` q-5 gry , 'T-A/S ,1,2 11A-
0 ❑ Ccrfi icd copy is hereby furmshed FIRE SPRINK ENERGY T-24
Z Z Certified copy is fled with the 'Ty in:me l� ivisio
A ¢ant / MISS.- REFER TO ORD. v N v N
E- L l ° ��C�EIr� ❑ ❑ ❑ ❑
Cr W CERTIFICATE OP Ii%li\IPTION FROKIi! PERMIT ISSUANCE 10.00 64 - PL000 ZONE A.L.U.c.
LU > COMPENSATION INSURANCE V PLG.CONTE. LIC.NO. PLG
m . �/n
d 0 (This section need not he completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
2 hundred dollars IS 100)or less.) r
U 0 1 certify that in 0m performance of the work lit,which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
IL F mit is issued,I shall not employ any person in any Imemrr,so as to
0 become subject to tiro Workers'Compensation Laws of California.
0 i Uate Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTI C Ii'1'0 AIT LICA NT: If,after making this Ce H i ficate of 1.s.
I. ? CluMion,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 mmh provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10)00DC.F.M.) 4.00 �.
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,00DC.EM.) 6.0 SEISMIC FEE )?
Ihereby affirm that there is a construction lending agency for - EXHAUST HOOD(WITH DUCT) 5.00
the perforences of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). /�-�--� HEATING UNIT(TO 100,000 B.T.U.) SAO
Lender's Name ��(✓ HEATI NG UN IT ER 100,000 B.T.U.)9.50
Lender's Address '? �+ Aim w.r...'+r.. ELECTRIC
'I certify that I have read this application and ,,no that the above VENTILATION FAN (SINGLET 4700
information is correct. 1 agree to comply with all city and county - PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.or 100,0006.T.U.)�6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP(Over 1110,00.0 BTUI SEE FEE SCH. MECHANICAL �+
(We) agree to save, indemnify and keep harmless the City of MISC.- -'� REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST-TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 -r
g do r of
thi.pe....d MECH.CONT. LIC.NO. MECH.
-gam TOTAL TOTAL & 3 y
` 7 vi
Si azure f Applican/Con rS t Date 4NL:
INSPECTOR COPY "