09786 s a•`t 'APPJICANT`TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMITNUMBER
BeaOOING . I , APPLICATION & PERMIT
AODRESV
.�Q/ � �VE�s L ILDING — ELECTRICAL—PLUMBING—MECHANICAL 09786
OWNER'$ {, \ I F '�. m PLAN CHECK VALIDATION
.: NAME `T C LJ OL 7i1✓fJ pTY " -`ELECTRIC PERMIT s'�I+1r<•T7 FEE V
".l / / ONe {« of 4 Ih
..r i i, ill• v CON TRACTOfl'S
ME OUTLETS SWITCHES-RECEP 10.00/1.00 0/100
LIGHTING FIXTURES 10.00/1.00
52
ooeess ORE APPLIANCES-RESIDENTIAL 4.00
NE ,� PANELS 10.00 DATE OF APPLICATION
OgcHlTEt PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N .
ENGINEER
nLIC.No. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.0Q PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 - -
AMOTORS SEE FEE SCH.
ADDRESS OREEE ,V 1
SERVICE CHANGE 20.00 !J^/JI` (/�/J(/r✓I J'W'^�.//
w
02 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a U 1 hereby Affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
Iconmm nein, vith.Sectim,7000)of Div,um,3 of the Business and BLOC. ELECT. PLG. MECH.
Pra fessions Co a-a y license is in(all fojnJy1(wl� ❑ ❑ ❑
License Class Lic.Numbepr_���0Ov�33,y�' ' � kJ
E H I_ Uate - _Contactor_`Nys: V- al
wa OWNER-BUILDER DECLARATION As.',,i;i,BU1LDINGPERMITP�;yµt +
MISC.— REFER TO ORD '`.INFORMATION.",%i,.
A.
;N h I hereby affirm that I am exempt from the Contractor's Liceroc ,VALUATION S/FT.
o a Law for the iollowiny reason.(Sec.7031,5,Businessand Nad,ssimu
r =m PERMIT ISSUANCE 10.00
improve,demolish,
county any structure,
prior
oconsuance.nq
a Q Q 0 1111p1nvl•,de1110hiI1,Vf repair any ih VClllre,prlt)f In Its Is]ua+ICL',aSV ELEC.CONTR. LIC.NO. ELEC.
Aa
E O u requires the applicant(or such permit to Isle a signed statement that TOTAL r� p PERMIT TO
m m m he is licensed 9(commento cing
withprovisionsSection
of the Contractor's License
'r z a Business
(Chang P,.commenC ndwith Seuhon 7000)of DivisionrciHin the Iryh. -(fJ ✓ N+V
14 O the basis and PrtA'assmns Code)or that ha•isexmnf a ron 70 unJ DTV.' PLUMBING PERMIT+, n uFEE.I
- a I- the basis for[he Alleged exemption.Any viulatiun of Section 7031.5 -+ - STORIES TYPE CONSTR.
a '; by any Applicant lot u permit subjects Nle applicant loo civil penally ALTER-DRAIN&VENT-WATER IEA.)•5.00
of nut more than five hundred dollars(S500r):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 DCC.GHOUP RES.UNITS
their sot,compensation,will do the walk,and the structure is ,,It
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON
Code:The Contractors License Law sloes not apply to an owner of
property who builds or improves thereon,and who docs such wart, FIXTURES-PER TRAP SO.FT.FLOOR AREA TOTAL ACREAGE
_ himself or through his own anployecs,provided that such improve
mous are not intended or offered for sale.If,however,the buildin, GAS-EA.SYSTEM-1 INC.40U S -
�— or improvement is sold within are year of cmnpletian,the owner-
builder will have the bas Nen of proving that he did not build or int- GAS-EA.SYSTEM-OVER 4 ( BUILDING USE
prove for purpose of sale.). RES IND CON PB Diner
CI 1,as owner of the property,Air exclusively contracting with INDUSTRIAL WASTE INTER. 0 ❑ ❑ ❑ ❑ ❑
licensed coult"tun to c.nlluo the project l Sce.7044,Business LAWN SPRINKLERS-11NC 5 ASSESSORS PARCEL NO.
and Professions Code:The Contractor,License Law does not apply
to An owner of property who builds or improves thcmon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contracla{s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft110.00
the Contractor's License Law. Q TRACT NO. PARCEL NO.
❑ Into exempt under Sec. ,B.&BC.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPRNSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of convent to lel Ginsure, j
or A certificate of Workers Cum venom Ion Ins Q c.T OQ .F.. ZONING
I 4r cc o� tiJ e`-1 aFI' ENG.SITE N0.
copy thereof'(Sec.3800,Lab Cp,in, v ,
Policy No. Company— yn/si
❑ Certified copy is is fehy furnished. FIRE BPRINK ENERGY T-24
..Z ❑ Cmlified copy is I11eJ ah 1he city�inspect)Pn division.
F- Applicant. ,X1,^[-ALIs •�y.S.i�.cn.l MISC.• REFER TO ORD. Y ❑ N❑ Y ❑ N❑
CC CERTIFICATE OF EXEMPTION FROM__WO__RKEE�RRS' PERMIT ISSUANCE 10.00 (J FLOOD ZONE A.L.U.c.
UJ COMPENSATION INSURANCE PLG.CONTH. LIC.NO.- PLG. /••s (N
CL O (This section need nut be completed if the lief..it is for one TOTAL tJ Y❑ N❑ Y [:] N❑
Z hundred dollars IS 100)or less.)
U O I certify That in the performance of the wmk for which this pc- pTY. `° MECHANICAL PERMIT ' ;FEE" f - ''.FEE'SUMMARY 11..'
.LL 1- mit is issued 1 shall not employ any person in any manner so as to s
O w became subject Io the Workers Campensuliun Laws of Cu l it. oi,.
y Uute Applicata BUILDING
} N ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If,after making this Cenificat,01'fix-
(... Z emption,you should became subject to the Workers'Can,p...ahon APPLIANCE 5.00 PLAN CHECK
prisions of the Labor Code, you must forthwith comply witlh
U
such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10)=GF.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 10400GflM.) 6.00 SEISMIC FEE
I hereby affirm that there is A c0nsuuctiun Icndinit aSency for EXHAUST HOOD (WITH DUCT) 5.00
the perfonnmme of the walk I'ur which this permit is issued(Sce. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that l have read this application and shute that the above VENTILATION FAN (SINGLE) 4.00
infornatiun is correct. I agree 10 comply with All city and count, PLUMBING
As I,old H" cs and state laws relating to building conslrucliun, and BOILER-COMP 13 H.P.or 100,000 B.T.U.) 6.00 d
above-mentioned hereby su0mree propereprcserlynwti
forinipeciiovns utt thisnpurpocity setos.enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
IWe) agree m save, indemnify and keep harmless the Cu, of MISC.• REFER TO ORD.
Cupertino agpilnl liabilities,judgments, .,L, and rxpensns which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue id City in u,Hscqucn,c uI It,,
iV\ , Iny a(ihii pemhiL MECH.CONT. LIQ NO. MECH. -
\X/ _
$ignalmea Applcanl s Ate—
TOTAL ' TOTAL`',
OFFICE COPY