C7264 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECTIDENTIFICATION PERMIT NUMBER
BUILDING �2�fy APPLICATION & PERMIT 64
ADDRESS n r G
�- BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 72
OWNER'S s_ PLAN CHECK VALIDATION
Y NAME$}eve Kris 157-43Z�I OTY. ELECTRIC PERMIT FEE 3.77 fS
PHONE 3N-If2.5z 6_
CONTRACTORS UTLETS-SWITCHES-RECEP 5.00/1.00 G �'
NAME 7 r LL
.54e"Oe- Zan rc LICNo.&IyL1 (D LIGHTING FIXTURES 5.00/1.00
CON
DDREAciOR'S
AAPPLIANCES-RESIDENTIAL 4.00
ADDRESS
A 1L1TJ
Z &-oklie 6tYl PHONE Z.SM37-9 PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.66 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.NO SIGNS TRANS. 3.00
nooeess ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE I-
A
1l-
APPLICANT'S .I Tkll�le4fsI
J
POOR Eu MOTORS SEE FEE SCH. .
SERVICE CHANGE 10.00'
wo o - ✓ LICENSED CONTRACTORS DECLARATION
¢ o U N I Itereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
ya y/ (commencing with Section 7000)of Division 3 of the Rosiness and BLDG ELECT. PLG. •MECH.
F o z Nofeoioms Code,ajall my license is in full force' ff h ❑ E]z Oz m - Liconic Class Lie.Number �^
0r 0 Datc Contractor
¢ x f h i BUILDING PERMIT
¢ ¢ w ¢ OWNER-BUILDER DECLARATION INFORMATION
w
Car I hereby al't'irn that I um exempt from the Contractor i License
MISC.- REFER TO ORD
LL o
Lawlor the following reason.(Sec 7031,5,Businessand Profusions PERMIT ISSUANCE vnLuniloN S/FT.
�- Code:An II or county whichte uiresu rruit toconstrucLulter, 6.00 /}
�'Q ¢ p improve,demolish,or repdir any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. r�-11000,
D 0 requires the applicant Or such permit to file a sighed statement(flat TOTAL
a w m u. Ile is licensed pursuant to the provisions of the Contractor's License c:12/ PERMIT TO
r- za
Law(Chapter 9(commencing with Section 7000)of Division 3 of the /
4 0 Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ F the basis for the alleged exemption.Any violation of Sect inn 7031.5 STORIES TYPE CONSTR.
a3 � by any applicant for apermit subjects the
applicant o a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more thf
Iran five hundred dollars(55001.1:
❑ I,as owner of the property,or my cmployccs with wages as BACK FLOW PROTECT. DEVICE 2.00 oee.ckouP 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's License Law does not applyto an owner of ...+
property who builds or improves thereon,and who docs such work F IXTUR ES-PER TRAP 4.00 SD,FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale.IL however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00 3o /
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have thr,burden of proving that he did not build or im- RES IND CON PB Omer
prove for purpose of,cH,). INDUSTRIAL WASTE INTER. 20:00
❑ I, is owner of the property,ani exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors In construct the project(Sec. 7044, Ifusloces LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL No.
and Vnil'e,ions Code:Thn Coutructor•s License Law docs not apply
loan owner of property who builds or improves thereon,and who LAWN SPR INKLERS-OV ER 5(EA.) 1.00 36 u- -?0--1-7
co ilracts for such projects with a contractoes)licensed pi rstmot In
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under sec. ,B.S.I'.C.for this WATER.HEATER W/VENT 4.00
n'aum
Owlher Date WATER SYSTEM 4.00 ACC.DATE - ADO.FILE NO.
WORK BRS'COMPF-NSATION DECLARATION WATER TREATING EQUIP. 4.00
r I hereby alfurn that I have a certificate ofconsent loself-"'sure,
or
ZONING ENG.SITE NO.
a certificate of Worker"Compensation Insurance,or a certified
c thereof(tics 3800.Lab.C.1.
I'' No. Company nLM
O CeRiiied copy rt hereby furnish d. A.- FIRE SPRINK +ENERGY T-24
Z Z CeniOcd c i filed with the city tion division.
O Applicant MISC.- REFER TO ORD. Y❑ No Y ❑ No
Fy PERMIT ISSUANCE 6.00 FLOOD ZONE 'A.L.U.C.
- CIi R'I'IIIG OMPE E, TIOM1'FROM WOk KIi RS'
W - COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
Z) O (Phis section need not be completed if lire pernit is I'or one TOTAL Y❑ N❑ v [!] NE]2 hundred dollars(Sloo).,I...J
U O 1 certify that in the performance of lire work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- rel it is issued, 1 shill not employ any person in any Imamner so as 10
V become subject to the Workers'Compensation Laws of California - / G3 p•t
BUILDING
ED Dae Applicant ALTER OR ADD TO MECH. 4.00 (po
} res NOTICE*1'0 APPLICANT: It,after making this Certificate,of Es
F 2 eruption,you should become subject to the Workers'Conhpensation APPLIANCE 4.00 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=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE �[�(
1 hereby affirm that there is A construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00 ,
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,0,C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00 -
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify tial l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
• information is core et. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.
4.00 PLUMBING .\
ordinances and ,shale laws relating to building construction, and
liechy aafhoriec representatives of this city to corer upon the BOILER-COMP IOver 100,000 BTUI BEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(Wu) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. p
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX I y[G
may in any way auq
accrue against said City in conseucncu of Ibu
grunting tit this permit. MECH.CONT. LIC.NO. MECH.
_ _ TOTAL TOTAL 9`74'0
�/
Si Appli- ontractor Date
//� INSPECTOR COPY