9056 (2) .(sa3ist\PPLICANT TO FILL IN INFORMATION WITHIN HED LINES'- USE BALL PUINT PEN UNLY"
PERMIT NUMBER
ZN
LDING PROJECT IDENTIFICATION APPLICATION & PERMIT ///��y O �' C JUBUILDING-ELECTRICAL-PLUMBING-MECHANICALsie -Y'` PLAN CHECK VALIDATION
OTV ° ;t ELECTRICPERM1T�r tdl�ln,�r FEEryORs UTLETS-SWITCHES-RECEP 10.00/1.00
tr NO. LIGHTING FIXTURES10.00/1.00
rorvTRACT Rs PPLIANCES-RESIDENTIAL 4.00
DBEs)
l 8 ONE PANELS IO.00 DATE OF APPLICATION
ARCHITECT
PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.L.NO.
OR
ENGINEER
ucrvo. SIGNS TRANS. 3.00
.
ARCH.OR ENG. SPECIAL CIRCUIT 5,00 1;!6 '- PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00 _ )
APPLICANT s MOTORS SppdLACH. 0-�-
ADORESSooREss
SERVICE CHANGE 20.00
' W o D LICENSE CONTRACTORS UHCLA nTION
TEMP.POLE
<u u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANC DATE
D as ca (commencing with Section 701301 of Division 3 of the Business and pLpOt 1 BLDG. ELECT. PLG. MECH.
r n z Professions Codc nil n license is in full force a •Ify�. N ❑ ❑
0 a - Ltanse.n�Iaass�� A,)){� Number '"�i
w Dale�_�Ljf- Contreotor_
� "BUILDING PERMIT.,!! ^
w ¢ OWNER BUILDER DECLARATION ^(t';t-°i" ` � 5
U REFER TO ORD INFORMATION�r;;i!;
u r 1 hereby affirm that I am exempt from the Contractor's License MISC•- VALUATION $/FT.
v. 0 Law forthe fallowing reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 0
` Code:Any eityorcountY which reyui¢sapumit lis coutrucL altcq
Q ¢ 0 improve,demolish,ortepair any stmcture,prior to its issuance.also ELEC CONTN, LIG NO. ELEG. Q
O C requires the applicant for Such permit to file it signed statement that TOTAL PERMIT TO
w w m m he is licensed pursuant to the provisions attic Contractor's License v + f e
>
Law(Chapter 9(connmencingwith Section 7000)of Division 3 of the Fin C /
x a Business and professions Code)or that he is exempt therefrom and DTV. 'PLUMBING PEflM1T lr r. FEES;'
a
at the basis for the alleged exemption.Any violation of Section 7031.5 t i. I"'"' .��^.• '��' STORIES TYPE CONSTR.
a ; ,- by any applicant for a permit subjects the applinnt to a civil penalty ALTER-DRAIN& VENT-WATER (EA.1 5.00
.four more than five hundred dollars(15001.):
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their wit compensation,will du the work,and the structures not
intended or offered for sale (Sec. 7044, Business and Trots»ions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law docs not apply to in owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 gO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve
mems are not intended or offered for sale.11,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
f J sir improvnnem is cold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did nut build or int' RES IND CON PB Otherprove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ El❑ I,as owner of the properly,am exclusively comructing with
licensed contractors m construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:1'he Contractor's License Law does not apply
to an owner of prupeny who builds or impovrs thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORMEA.200ft/10.00 TRACTNO. PARCEL NO.
the Contractor's License Law.
❑ lam exempt under Sec. .U.&P.C.for this WATER HEATER W/VENT 6.00
reason
i (�wncr Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
s�Ok,V*B S'41111Fp'ST1 'rliC);.4tAT1ON WATER TREATING EQUIP. 5.00
1 mere y a um hist a rc r o on cnt to xl(-insure, ZONING ENG.SITE NO.
- or a certificate of Workers'Compensation Insurance,or a certified
copy thercuflSce.3800,Lab.0 ,.,-TD,NA
policy Na. Companyp,_l.
O ❑ Ce,lified 'opy is herehy furnished. FIRE SPRINK ENERGY T-24
Z Z Certif�e��j/L.o y is,GI ,(1'w'U/m/�t�he�/gyuy-inspection division. MISC.- MH
. y❑ NE] y ❑ N❑
F_ O pican t_Ub le'�Ib'-w-Y�4
CC CERTIFICATE 01:I:XFMI'r ON FROM WORKERS' PERMIT ISSUANCE FLOOD ZONE A.LLLL.
W COMPENS ION INSURANCL PLG.CONTR. LIC.NO. - y❑ N❑ Y ❑ Nd 0 Ilhs section need not be completed 1 the per it s for one Z hu l, dJllars(I 100)ur lea.)U O' 1 c ni y that nt tire performance of the work Ir r wh' h this per DTV. "' MECHANICAL -'"" I' e sl`FEE SUMMARY LL F mit s issued,1 shall not empluy any person in any mw n er w us to ,. )O w become subject to the NorkcriCompenwoun Laws ul Culilurna. " BUILDING
Uum Applicant ALTER OR ADD TO MEC
} a NO1'ICI7 TO APYLICAN'I': IL eller nuking this Cert it scute ul'Ex
F ? caption,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 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=r-F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.C.).
Lenders Name HEATI NG UNIT(OVER 100,000 B.T.U.)8.50 ELECTRIC 0 --
Lender's Address
I certify that I have re4d Ihis applicafion and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county BOILER-ODMIP(3 H.P.Or 100,000 B.T.U.) 6.001PLUMBING
ordinances and state laws relating to building construction and -
,i-Y )hereby authuriee representatives of this city to enter upon the 801 LER•COMP IOmr 100,000 BTU)SEE FEE SCH.1 MECHANICAL
above-mentioned property for inspection purposes.
(We) agree lis save, indemnily and keep harmless the City of MISC.• REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.001CONST.TAX
may in any way accrue against Said City in consequence of lire
grant ppf INS permit Y A MECH.CONT. LIC.NO. MECH.
V y� / .�p_�¢ TOTAL TOTAL`
Ss11nome of Alphc t/Coy- nNaT'tor E-rate
OFFICE COPY