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BUILb1N0 PpOJkCT,IDEN?I kICdTION "
I -PIIR MI,rJUMgI In
_Jx
amLeING: colt1c,1APPLICATION & PERMIT r7
/� vKA_G(7 I���t?'llil AR"� BUILDING -ELECTRICAL=PLUMBING -MECHANICAL � T,
NxMERa ' ♦f 1 lr!I Ily }rl� �-i �T lf' 1 �11f �. r1.nN 1.�IffY VnLlpnllrlN
�. �IGNI Ste'Vl,�• 1 I iia}( f'.�4,tli.Yi1+ yj�(ELE�TR' P IT:Iis FEE
MONELIL �SI�o ' I f I 'I '
AMERnL*°Ra UTLETS-SWITCHES-RECEP 5.00/1.00
OL �C�/ U1L c.rv0.3 LIGHTING FIXTURES 5.00/1.00 Gb
C,ONTRACTOR'a
l\ AooREssfyfiq NI IC PPLIANCES-RESIDENTIAL 4.00
`d0S LCf kiwb(19F1C.Mm 10 / PANELS 5.00
Dnl l UP APPLICATION
ARCHITECT
[ Ill PLAN CIH GI:Put, r IJ 1
ENGINEER 1 "' SIGNS 6.00
LIC.No. SIGNS TRANS. 3.00
,\ ADDRESS as ENG. C r
SPECIAL CIRCUIT 5.00 I'.nann nl.lnn LL';I„
E-LaCUO pLtS GA//O g,y yyr EMP.METER OR POLE;INS. 15.00
ADORE.l'a /a� .
ADORE.
MOTORS i 'SEE FEE SCH.
0E9*17/ 4+-7D/Z- SERVICE CHANGE 10.00
ori
II m g LICENSED CONTRACI'OR3 DECLARATION
a u u I hereby affirm that I am licensed under prov0lom of Chopler 9 ISs!nrucr;on f: _
N a IINw I El
Irnmmesming with Section 7000)of Division 3 of the Business and Fit I cLEr,n 7,77-1- mlcr.
' n Pmfevslune CnJrtyd my license it,In full to
o u`� Llceme[I�ssl F)' " CLic.on N ctorI Z J
,AF J 'Ual<_LS Ln.}! Conlrecfar(ac -I
BUILDING PERMIT
C,w OWNER-BUILDER DECLARATION INFORMATION I
A. I hereby affirm that l em exempt from the Contractors License MISC.- 1 REFER TO ORD
wo¢ Law for the following reason.(Sec.7071.5,Business and Professions °nl,un n!,N SJFT.
; �a -' Code:Any cityor county which requires a permlf to construct, PERMIT ISSUANCE 6.00 V3L. 0�0 �
not ¢ O improve,demolish,or repair any structure,prior lolls iffuancq also ELEC.CONTR. ( LIC.NO. I O
O, requires the applicant for such permit to file a signed statement that Y 1 TOTAL 6ELEC PSHNI t 10
--
w$m he Is licensed pursuant to the withSecti of the Contractor's License ` I I / �
Lew(Chapter 9(commencing withSection 7000)af Ulvinion3 ofthe ttz.i&'1i 4 (s'U•.y1" S aiIGR6^IAIIPe :{I i'
z O Business and Profemi°ns Code)or that Ile b exempt therefrom and GTV'g$j{faI PI:U �I PEI>� IA'IT�'a1{�F I C, - I• FEE _
IF l-� the basis for the alleged exemption.Any violation of Section 7071.5 t ,;.� E$N': .Ik IfLyl1. j 14 {}j T ,_t , Ir 510RICA --it r[[tIrvST R
.f anyapplicantthe fire uncle dollarslite(IIS( plicont loo civil penally ALTER DRAIN St VENT-WATER (EA.) 4.00 n �(,I�F.V/�
.fact more owner
five hundred Dollars(my employees
�,.! _-- /�
❑ L m owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC,Gunur Ins,IINI IS -
their Bole compensation,will do I�,e work,and Iha structure Isnot
intended or offered for Sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 f
Code:The Contractor's License Law does iso,apply to an owner of � ------
property
_ _-
ropertywhobuildsorimprove,thereon,and who does such work FIXTURES-PER TRAP 1, 4.00 50 Fr ru�nu III.ll vilestncln:nG,
Pm through his own employees,provided that such Improve-
renisarenotinlenJeJoroffered forsale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4,00 ����
improvenenf b mid within one year of completion, the owner-
Ilder will have the burden of moving that he did nor build or Im- GAS•EA.SYSTEM-OVER 4 (EA.) 1.00 uun.uun:u;a:
rare for purpose of fele.). Is[S INTI C1) I'll ndl•I
❑ Las owner of the property,am exclusively contracting will, INDUSTRIAL T N pp 20.00 �- ❑ LI
licensed watracim, to construct the project(Sec. 7044,Business LAWN SPR IN -1 .8 5.00 nsslsguls:n•nir:r l-Nu
and n owner of Cole:The who
o License Law deet not apply ��-- C✓
to Contracts
owner of properly who bacon or Improves thereon,and who LAWN SPRINK OVER 5 I aq 1.00
the Contractor's
for such project with a comraclor(s1licensed pursuant to 'O
the Contraclori Licenu law. i u SEWER-SAN IT M. Oft/6.00 irnn:% Nn-"'- inlicEn.
❑ 1 am exempt under Sec.- _;BdP.C.for this
reason -.max WATER HEATER W/VENT I 4.00
Date - Owner - WATER SYSTEM PAM 4.00 - nrc,noir'- nr,C-F n.1.No-
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP." 4.00
I hereby niton that 1 have a certificate of esna nl to self-insuu,
nr i Ceof Workers Compemallon Insurance,or a Certified. 'ONINO EIJG SI IE rJO.
SO TheaSppmG
,
Policy Nola1LL o, n �rl Q.�1N13 win r
0 O CerllOed copy is hereby furnished. rwE$1'RINr. [nHu:/T.x4
Z Z ❑ C-erlrfred u, le int the int eclien division. N� _� N�
� Q Appllcanl_G � MISC• REFER TO ORD.
CER'iIFICATF.OF EXEM N FROM WORKERS' PERMIT ISSUANCE 1 ' 6.00 rIO(O zoNI �
W COMPENSATION INSURANCE rLG.CONTR. LIC.NO, rLG,
CL O (This section.need mol be completed If the permit is for one TOTAL v❑ +�"-Cf-++T�
Z handled dollars 100)or be
a v II IIn ./IE tp11'1 ','!1 S I'{4
U _O I certify shpt in the performance of rhe work for which IhM per. $•rel fi F ` I'MECN NICb�L PEf`1MIT's FEE FEE SUMMARY
LL mil is Issued,I shall not employ any person in any manner so ax to e i i•(�[e( {r n y: -r sit' lI. -------
become subject In the Worker'Compensation Law,of California. IVY 2f i�r H11 Iv I+ . ' .I I s.
0 w Dec ApplicantBUILDING -'41- T
} sift NO1ICF. TO APPLICANT: If,offer making this Certificate of Ex. ALTER OR ADD TO MECH. 4.00
Fn=i
Z carrion,nyou should become subject to Ilse Worker'Conmensa _
llon APPLIANCE 4.00 PLAN_CIIECIC n :;
provisions of the Labor Code, you must forthwith country with FEE
U such provisions or Ibis permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 3.00
CONSTRUCTION LENDINCAOENCY AIR HANDLING UNIT(OVER 10MC.F.M.15.00 SEISMIC FIHi </ f.!
1 hereby affirm that there B a consoncflon lending agency for EXHAUST HOOD (WITHIDUCT) 2.00
the performance of the work for which this permit Is Issued ISec. MICHOFILM
70,7,Ci,,C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender',Nasne_�U
Lender',Address • ' H EATI NO UN IT IOV ER 100,000 B.T.U.17.50 ELEC TRIC rjl/I
I certify that I have read this application and state that the above VENTILATION FAN ISINGCE) 3.00 ----- _-""-'-
Information Is correct. I agree to comply with all city unit comely PLUMBING
dinance, and ,tale law, relating no h,tllding consl'uction, and BOILER•COMP(3 H.P.or 100,000 B.T.U.) 4.00
sehy authorlee representatives of tills c11k' to eater upon the - - ----� -- ---- --- - i
ave-mentioned properly for Inspection purposes. BOILER-COMP (over 100,000BiU)SEE FEE SCII MECIIANICAI.
(we) agree to save. Indemnify and keep Imrmler the City of MISC.- I REFER TO ORD. ---
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX I
may In any way accrue'against mid City In c use notice of tine
grantin}yf linix nit. MECH.CON'. LIC.NO.. ML(91, l .if
k /rid L Z IOTAI I TOTAL
Signatuteof APpliee t/' ntnclor Unl - -I _--_
OFFICE COPY; "(
i .