6328 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
BUILDINGPRO3ECT IDENTIFICATION APPLICATION & PERMIT
BUILDINADDRESS
ppr 6328
1�d�( ADOREss T S �G �/(] BUILDING-ELECTRICAL-PLUMBING-MECHANIC
I ^-S- O NFP p��♦�/ PLAN CHECK VALIDATION
Iltt ""vE QQ -yJ��yL� �If lw/ '�yy OTY. ELECTRIC PERMIT EE (�
• �rr VI"� .- eNorvEG/7'7 dd•J 7 ��(
NAANtRACTORs - p UTLETS-SWITCHES-RECEP 5.00/1.00
NA //
t NO O LIGHTING FIXTURES 5.00/1.00
/
Ano E55TOHs PPLIANCES-RESIDENTIAL
S.J. ab -31s
PHONE PANELS S.00 DATE OF APPLICATION
R ENGINRE[L
RM ,74- CN$ 6.00 N HECK FEE P.C.NO.
LIC,N91" SIGNS
TRANS.' 3.00
ARCH,OR ENG, PERMIT VALIDATION
ADDRESSSPECIAL CIRCUIT .5.00
qzo �4++`4 1111 LN/74EMP.METER OR POLE INS. 15.00 — r
AEPLICDOREA NT's C U 60/CA 9 9 G5A6L SCH.MOTORS SEE FEE ''U
ADORE,
102A4 PAR ,tf SERVICE CHANGE 10.00 ��S/p
woo �
LICENSED CONTRACTORS DECLARATION Q
¢ o U I hereby within that I ton licensed under provisions of Chapter 9 ISSUANCE DATE
H <m (commencing with Section ]000)of Division 3 of the Business mtd BLDG. ELECT. PLG. MECK
F m z-- Professions Cody nd my license is in full fore and effect. /
'z o m- hicrosu Class__ - _Lic.NumberT�
Dale r_f L Contractor
mL - =l O s✓
BUILDING PERMIT
¢ ¢w c OWNER-BUILDER DECLARATION INFORMATION
ra MISC.- REFER TO ORD
w 3 LL H I hereby althea that 1 alit exempt from the Contractor's License " VALUATION $/FT.
' Fa O< law for t he followingrcmron.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00'
,A ANO.Code Any city or county which requires a permit to construct,alter. LIC. e�
- ¢ a a o improve,demolish,or repair any structure,prior to its issuance,also ELEG.CONTR. ELEG 7
O, requires the applicant fur such permit to file a signed statement that TOTAL PERMIT TO
a Som lie is licensed pursuant to the provisions of the Contractor's License SIA,*L E fhlM/[
i1Law(Chapter7(commencingwith Section 7000)of Division 3 of the
a'` Business and 1'rotessinns Code)or that he P exempt therefrom and QTY. PLUMBING PERMIT FEE / WE= L i
f i o j
the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
,of
anyapplicanl Porn permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00 - a s w/�
of not more than,live hundred dollars($500).): i1,
❑ I,US owner Of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 2.00 OCG GROUP RES.UNITS
Their sole compensation,will Jo the work,and the structure is not
Intended or offered for sale (Sec. 7044. Business and Professions' DRAINS-FLOOR,ROOF,AREA,COND. 4.00 /,1 �_ 3
Cole:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such Y1�ork FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or Ih rough his own employees.provided that such in.Prave-
ments are of intended or offered for sale.If,however,the huilJing GAS-EA.SVSTEM-11NC.40UTLETS.q,00
or improvemmul is sold within ane year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not huild or int- RES IND CON PB Omer
prove nor purpose of sale.). INDUSTR IAL WASTE IN ER. 20.00
❑ I,as owner of the properly,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 AiaSORSPARCELNO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves tlurnns,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to
the Contractors License Law. - SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
- ,❑ lam exempt under Sec. ,BAKC.for this WATER HEATER W/VENT 4.00
Ower Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSA1 ION DECLARAT16N WATER TREATING EQUIP. 4.00
I hereby affirm That I have a eurtiliente of Conant tosell=insure, ZONING ENG,SITE NO.
In a certificate of Workers'Compensation Insurance,or a certified
� copy PolcYNoc"r;lsec'3T "N.C.). rHV
Y
6` (7J T�f
❑ Certifie spy lslmre Y umished- FIRESPRINK ENERGVT-24.
z Z q�� Q•rtifieJ copy is riled with the city inspection division.
AppNi1CVi I` Cd ,9 - s—y MISC.- REFER TO ORD. — YE] N❑ O
Y❑ 'N
w CER'I'IFICATi OIs EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00' FLOOD ZONE A.L.U.C.
W-> x COMPLNSA'1'ION INSURANCE ?LG.CONTR. sec.NO. pLG.
OL O (This section need not be completed if the permit is for one TOTAL / '� y❑ NE) Y❑ NE]
D Z hundred dollars(S 100)or to..)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,1 shall not employ any person in any manner so as to
U become Subject to the Worken'Compensation Laws of California.
O w BUILDING
y Dutc Applicant ALTER OR ADD TO MECH. 4.00
} to NOTICE'1'O APPLICANT: If,after making this Certificate of Ex-
F Z emptian,you should become Subject to the Workers'Compensaion 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 10,000C.F.M.) 3.00
f CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000 C.F.M.) 5.00 SEISMIC FEE '
I hereby affon that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00 a.1-
the performance of the work for which thfi permit is issued(Sec. MICROFILM
3097•Civ.C.). y-- HEATING UNIT(TO 100,000 B.T.U.) 4.00 -�•
Lender's NameERCT !- � 1-/S/ ' HEATING IT(OV ER 100,000 B.T.U.)7.50 ELECTRIC
j -•-T.v� :r
LeWer's Address � ,i
Icertifythatl have read lhisepplicatiolSaygstttexf goryt o above VENTILATION FAN (SINGLE) 3.00
• information is um.meet. I agree to comply wAh all city and county PLUMBING
ordinances and State laws relating m building construction, and BOILER-COW 13 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL D-,
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, coats and expenses which CONST.TAX
may in any way accrue against said City in consequence of the,t PERMIT ISSUANCE 3.00
gra Ling of this Perm MECN.CONT. LIC.NO. TOTAL
� Yf ��: ?- 4! �� �y TOTAL
Sag to L n Apph t onUftel�'� Dot /
INSPECTOR COPY ,