C5047 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT5� A`�
/f
AOovsss - WLDING -ELECTRICAL-PLUMBING -MECHANICAL (If
10001,510101 N. DeAnza D
NAM1IERS E 'x/2N YL�-2/� (}O B/ LAN2HECK VALIDATION
. ATV. ELECTRIC PERMIT FEE
-Ko-�l-C-b. PHGNE280-6400
CONTRACTOR$ UTLETS-SWITCHES-RECEP 5.00/1.00
NAME C16-26170
S&M Sprinkler CO3;p.N LIGHTING FIXTURES 5.00/1.00
CONTRA TOR APPLIANCES-RESIDENTIAL 4.00
°REGkeawood City,CA
• - PHONE PANELS 5.00 DATE OF APPLICATION
' ARGHDECT , SIGNS 6.QQ PLAN CHECKFEE P.C.NO,
OR
ENGINEER
uc.NO. SIGNS TRANS. 3.00
nooa'Ess eNe. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zip TEMP.METER OR POLE INS. 15.00 ['
APPLICANTS MOTORS SEE FEE SCH. J
oORESs
SERVICE CHANGE 10.00
0 0 o LICEh'SIiD CONTRACTORS DECLARATION J ///6
G U I hereby uffinn Etat I con licensed under provisions ut Chuptel9 - ISSUANCE DATE
y z er (commencing with Section 7000)of Division 3 ofthe Businessand BLDG. ELECT. PLG. MECH.
r H z Professions Coif n6any license is in full force a fay ❑ ❑ ❑ ❑
z o,ss - License.Class "l�x�+ Lig.Number Z•� `O8
o z H w Date 2�2�'r-v3 Contractor
a y fr-M-Spr nk7 er BUILDING PERMIT
w a OWNFR-BUILDER DECLARATION
oAo MISC.- REFERTOORD - INFORMATION
wLL I hereby affirm that I am exempt Iran the Contractor's License
LLOa Law for the following reason.(See.7031.5.Businessand Professions PERMIT ISSUANCEVALUATION $/FT.
� w 2Code:Any city or county which require permit mconstruct.alter. 6.00
Qto j O improve,demolish,Or repair any structure,prior to Its issuance,also ELEC.CONTE. LIC.NQ ELEC. 39 761,
ad
- m ¢ requires the applicant for such permm
Reprint to file a signed Set that TO. P PERMIT TO
ea he is licensed pursuant In the provisions of the Contractor's License
H z i
Law(Chapter 9(cummcneingwithS,ction 7000)Of Division 3 of tic install
a business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
mon
o the basis for the alleged exemption.Any violation of Scction 7031.5 5 qj L arramen,
P. T by any applicant for a permit Objects pre applicant too civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(S5001J:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sale cum pensation.will do the took,and tie stricture Is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4,00 -
Code:I lie Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who AAs such work FIXTURES-PER TRAP 4.00 s0.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.Provided that such improve-
centsarc 'let intended or offered for sale If.however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4-00
Ill improvement Is sold within one yen,of completion,the owner GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or ice- RES IND CON PB Omar
prove for purpose of snliJ. INDUSTRIAL WASTE INTER. 20.00
C3 1, [I El El ElI,as owner of the property,ams exclusively contracting with
t_ licensed contractors to construct the project(Sec. 7044,Business / LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:'I'he Contractor's License Law does not apply '
to am owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
mtmets for such projects with it cnnlmUnri O licensed pursuanl Iu
! the Contractor's Lice ns.Law, I SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
re❑Irl:un exempt under Sec. .tl.'&I'.C.for this WATER HEATER W/VENT 4.00
aso
Dare r Owner WATER SYSTEM 4.00 ACO.DATE ACG FILE NO.
WORM i RS'CO,MPENSA'I[ON DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that 1 have a certificate of consent to"elf-insdre. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation'lnsurmme,ora ,nitieJ
copy tlj�,¢of(Sec.3800,Lab.0 1. I I
Policy vhi�/o pf-ompiny-Z }�
O ❑ Cerutu, copy' ,hereby furnT5 ,Cy htr FIRE SPRINK ENERGY T 24
Id Certified entry is tried will v city- tion division.
Z Z v MISC. - REFER TO ORD.
� O nppbrmm, ���r v ❑ N❑ v ❑ N❑
m PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.uc.
ft. CIiRI'I FICCON OF Ii XIi.M('TION E'RO)1 K' RIiRS'.
W CON INSURANCES / PLG.CONTE. LIC.NO. PLG.
d O (1[,is section need not be completed if the Permit is for one I f _ TOTAL Y❑ No Y ❑ N❑
Z hundred dollen,IS 1001 of c,1J I
U O 1 ertity that in the ps for d,nec of the work fur which this pee QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is mound. I Shall not.nn Ploy:my P,raon in any iinu ne,sings to
U become subject to the Workers'Compcnsmion Laws of CWiforniu.
U SO n. Dam Af pincant - " ALTER OR ADD TO MECH. 4.00 BUILDING
>_ to NOTICE: rO APPLICANI: IL after making this Certificate'of Ex-
� Z v-ntption.you should become subject to the Wcol ,is'Comptoodamn APPLIANCE 4.00 PLAN CHECK
provisions Of the Lahnr Code, oilmust forthwith v(... fly with FEE 154.U atoll provisions m this pc°nit shall be danced revoked, AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONS'T'RUCTION LENDING AGF,NCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00 VU
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that l have read thisapplication and state Enat Dmabore VENTILATION FAN (SINGLE) 3.00
. -in t inumion is correct. I agree to connply with all city'and county PLUMBING
orAinances and stat, laws relating in building conMrunfom and BOILER-COMP(3H.P.or100,000B.T.U.) 4.00
hereby authorii, relrevcntatives of this city, to enter upon the BOILER-COMP (Over 100000 BTU)SEE FEE SCH. MECHANICAL
uhovc-m,ntiuned property for inspection )urposes.
(We) ague. to save, indemnify and keep ha,nuc,, the City of MISC.- REFER TO ORD.
Cupertino against.liubilifies,judgments, costs and es penses which PERMIT ISSUANCE 3.00 CONST.TAX
may l any way "ecru, against said City in consequcrev of the 9
gm !ng of this permit. MECH.CONT. LIG NO. MECH. TOTAL O
TOTAL
Signatureat Applicant/Co ractor &M
Date
INSPECTOR COPY