16847 APPLICANT TO FILL IN INFORMATION,WITHIN RED LINES.- USE BALL POINT-PEN ONLY
BUILDING PROJECT IDENTIFICATION " - - "PERMIT NUMBER -
BUILDING _f.. 1( - APPLICATION & PERMIT
' 4ADOREu; n rvo + �R 1'6847,
C �
loiGb SBUILDING _'ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S ./µ,_ w' PLAN CHECK VALIDATION
NAME
.. ..
R I c4 Dr lyc/r{ '?3L-?lel OTY. . ELECTRIC PERMIT FEE' �
ONE
CONTRACTORS
NAME /�-QM'1'C'• - UTLETS-SWITCHES-RECEP 10.00/1.00
L c.NO LIGHTING FIXTURES`'• '10.00/1:00
CONTRACTOR'S APPLIANCES RESIDENTIAL, - 4.00 n
ADDRESS 1 _ (^2t-
I PHONE PANELS. 10.00
DATE OF APPLICATION :
ARCHITECT - e PLAN CHECK FEE P.C.NO: .
.
on PANELS (OVER 200'AMP) '- 20.00 . ..
-.� - ENGINEER.
' sec.NoSIGNS TRANS.' 3.00 � - ,' Ic; -
ARCH.OsENG. SPECIALCIRCUIT 5.00 PERMIT,VALIDATION
- ZIP, TEMP.METER OR POLE INS.,.; 20.00
I APPLICANTS MOTORS` . 'SEE FEE SCH.
ADDRESS
SERVICE CHANGE, .:20.00 f
t000 LICENSED CONTRACTORS DECLARATION
c v c, 1 hereby affirm that I am licensed under Provisions of Chapter 9 - _ ISSUANCE DATE, -
I" ('eri nencing with Section 7000)of Division 3 of the Business and
m a t+ .1 BLDG. ELECT. PLG. MECH.
r w i Professions Code,and my license is in full force and effect. ❑
Z o 0 License Class Lic.Number
o
Z I- au Date CORID"Un, ,. , :�a
F - J
-a E J - �� a BUILDING PERMIT
Stow a OWNER-BUILDER DECLARA'I']ON. 4 y.. Clry-Of CU"e1�In0 B ,
D A O . MISC." - I REFER TO ORD INFORMATION
: 't ; LL F I herebyraRirm that I am exempt from the Contractors License .
u o'� Law for the following reasou.(SeC.7031.5,Businessand Processions .pERM1T'ISSUANCE "' - " '10.00' VALUATION $/FT.
� - Code:Any city or county which requires a permit reconstruct,after,
R Q 40 improve,demolish,or repair any structure,prior tails issuance,also ELEC.CONTR. 'LIC.N0. ELEC. (7 -0 DD
a
D u requires the applicant for such I ermll t t HIt a i fined st mntenl that f .- .TOTAL PERMIT TO _
w $ het licensed pursuant to lire pro s m`-of the Cohmictor's License
i Law(Chapter 9(commencing with Section 7000)of Division 3 of the
-o, Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
I $ •- the basis for the alleged exemption Any viola(o t ofSection 7031.5 - .STORIES TYPE CONSTR.
( a ; by any applicant for a permit subjects theapplicant ton civilpenalty � .ALTER-DRAIN -WATER�(EA.1.500 ,.
of not more than five hu nd red'dollars(8500).1: . -
1,as owner of the property,or my employees with wages as
Ifci7'sole compenxal iov,will dn.lhe work,and sire structure is not BACK FLOW PROTECT. DEVICE: . 4,00 'OCC.GROUP RES.UNITS
iitended or offered In, Sale (See.7044, Business and Profession, DRAINS=FLOOR;ROOF,AREA,COND."5.00 -
Code:Thj Contractor's License Law does not apply to an owner of
properly who builds or Improves thereon,and who does such work FIXTURES-PER TRAP. ., 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
6 himself or through his own employees,Provided that sach improve. -
meals are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4 OUTLETS'6.00 ..
or improvement is sold within one.,year of completion,the owner- GAS-EASYSTEM OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or.im . -
.. -' BUILDING USE .
prove for purpose of sale.): - - INDUSTRIAL'WASTE INTER.v - ' 30.00 RES IND. CON PB Omer
❑ I,as owner of the properly,run eiclusively conlructing with " ❑ ❑' ❑ ❑ ❑.
licensed contractors to construct the project(Sec. 7044,Business DAWN SPRINKLERS=1 INC'5 V.B.. 6.00 , ASSESSORS PARCEL No.
and Pro Cessions Cade:The Crnlaacka's License Law does not apply
to un owner of`property,who builds or improves thercon,'and who LAWN SPRINKLERS-OVER.5(EA.)' 1.00 . . q
contracts for such projects with a'contractoAs)licensed pursuant to SEWER-SANITAR V-STORM EA.200ft/10.00
the Contractor's license'Law.' TRACT N0, PARCEL NO.
❑ 1-am exem oder ec B,&P.C.fllr Ibis WATER.HEATER W/VENT'• '' fi.00 '
- reason_ -
Owner Dale - --WATER SYSTEM. 5.00 -
_ ACC.DATE' ACL.FILE NO.
WORKERS;COMPL SATION DISCLARAI]ON ' ' r WATER TREATING EQUIP.. . •'r -5.00 -
•. 1 hereby affirm tial I have a certificate Cif consent to self-insure. • .
or a certificate of Workers'Compensation Insurance,or a certified r n ZONING ENG.SITE NO.
.. 'opo thereof(Sec.3800,Lal,.0-). -
Policy No. - Company . "' p _
O ❑ Ceftiliedeopy is hereby furnished. FIRESPRINKENERGY T 24
Z Z, ❑ Certified copy is Bled with the city inspection division. -
O APPbC Ill ' •' MISC.- REFER TO ORD. Y'❑ N❑, v❑ "NE]
G:'N CERTIFICATE OF EXENIPI'ION FROM WORKERS• _ PERMIT ISSUANCE 10.00 L.00 FLOOD ZONE A.L.U.C.•
` LU COMPENSATION INSURANCE PLG.CONTR. sec.No. PLG.
CL 0 •frhis section need'not.he cotilplcted it"Ilio pmulit is far one TOTAL O -"� - Y,E]. N❑ Y ❑ N❑
Z) Z hundred dollars IS 100)or less.) - - -
U O 1 certify mat in the performance of the work for which this per- DTV. _ MECHANICAL PERMIT - FEE FEE SUMMARY
F mit is issued,'1 shall not employ any crson' any manner so as to
w bermqe�su�I�IIyy..tJ9{he Workers'CoI n'ti sol Cvlilornia.
D! n- lirem_ . .BUILDING / Q
a pp ALTER OR ADD TO MECH. 5.00
} 0 N(ITICE '1'O APPLICANT': I ,of -r making Hg'ertibeate of fix.
�
Z,, ait,own,y ut slmuld become subject m the W r Ts Compensmlon
APPLIANCE - 5.00 PLAN CHECK,
piovlssonsbf the Labor Code, you most to Iwith comply with FEE a.
C� such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F:M.)' 4.00
CONST RUCTION LEND ING-AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMICFEE
I.hereby affirm thatllmrc is a constiuclion lending agency for EXHAUST HOOD(WITH DUCT) 5:00 "
the performance of the work for which this permit is issued fSec MICROFILM
30979 Co C.). - HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address 'ELECTRIC •-
I certity that I have read this application and state tllm the above VENTILATION FAN (SINGLE) _ 4.00
information is correct 1 agree to comply with all city and county - - PLUMBING
ordinances rind state laws relating m building construction, and BOILER-COMPI3 H.P.or 100,000 B.T.U.) 6.00 -
1 hereby authorize representatives of this city to enter upon the
above-mentioned_properly for inspection purposes BOILER-COMP (Over 100,0009TU1 SEE FEE SCH. MECHANICAL
®, a(We) agree t save indemnity and keep harmless the City of MISC.- - " REFER`TO ORD. -
Cupertino against Imolities,judgments, costs and expenses which - -CONST.TAX
ay In any wy cc I, against Bald Ceeq
Cut in'conuence of the PERMIT ISSUANCE t 10.00
nm[in hisP MECH.CONT. - LIC'NO. - MECH.,' '
TOTAL. '. , TOTAL
Signa ser of APPlicunt/C tractor '.Uri Yt ,I
-OFFICE COPY r