8477 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
rout-DING APPLICATION & PERMIT
ADDRESS
WJE BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 1 8477
PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
.�
PRONE
R CTORs
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
kkkbCuc.N LIGHTING FIXTURES 10.00/1.00
C ATi PPLIANCES-RESIDENTIAL 4.00
OOUs"
{{I-I-//11ft11
PNONE PANELS 10.00 DATE OF APPLICATION
OF PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE Plc.NO.
ENGINEER
uc.NO. SIGNS TRANS. 3.00
ARC H,OsENG.
SPECIALCIRCUT PERMIT VALI DATION
ADDR
ZIP rrEMP.METER OR POLE INS. 20.00
APPLICANT
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
0 O LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
F z uI hereby afhmG for I am licensed under provisions of Chaplet 9 ISSUANCE DATE
(co
4 mmencing with Section 7000)of Division 3 of the Business and BLOC. ELECT. / PLG. JIMECH.
F,e,i Professions d my license is in full fore an eRec ,t ❑ ,�,/ ❑
z o y - Licenu CI ss_ an_Lic.Bomber Y
v, H C Dara .ontract
Q y E J
¢ a 'O 'Nli - ILDER DECLARATION BUILDING PERMIT
-
a: o a v - INFORMATION
x ; u y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
1° u o 4 Law for the following reason.(Sec.7031.5,Business and Professions VALUATION $/FT.
_ N PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
ar ¢ improve,demolish,or repair any structure,prim to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
A. wO u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
m m he is licensed pursuant to the provisions of the Contractor's License
H z a
Law(Chapter 9(commencingwith Section 7000)of D)vrsion Sof the l
4 o Business and Professions Code)nr that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Section 7031.5 STDRIES tYPE ONS'ER.
uby any applicant for a permit subjects the applicant to aclvil,wnally ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(S500o.):
ED1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the s[rucmre is not
intended or offered for ,In (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CONIC. 5.00
Code. file Conlructor's License Law does not apply to an owner of
property who builds or improves thercou,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
ments are but intended or offered
mprove-mentsarenotintendedoroffered for sale.If,however,the building GAS-EA.SYSTEM-I INC.40IT' ETS 6.00
or improvement is sold within one year of completion, the owner. GAS-EA.SYSTEM-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. 30.00 REs IND CON B Giber
❑ I,as owner of the property,on exclusively contracting with ❑ _ B
licensed contractors to cunauict the project(See. 7044,Businesv LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code_'I'he Commetor's License Law dors not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OV OVER 5(EA.) 1.00
contracts for inch projects with a contractor(s)licensed pursuant to 16
file Contmcim's Licenac law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO( PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPEN'SATIONDECLARATION WATERTREATING EQUIP. 5.00 - .
I hereby affirm that I have a certificate of consent to sell-insure, ZONING ENG.SITE NO.
or n certificate of Workers'Compensation Insurance,or a certified
copy thercofl5ec.3800,Lab
Policy No. Compan q -
❑ Certified copy is hereby in sl FIRE SPRINK ENERGY LZ4
z Z ❑ Certified copy is filed Illi the �ily inspection division. MISC.- REFER TO ORD.
O Applicant/� �(� V N v N
f- rn r,•1.�,e -m'-yOs.�s PERMIT ISSUANCE 1
OC Ch.R'I'I PICCOMOP SAT FINS PROM WORKERS' FLOOD ZONE A.L.U.L.
W COMPENSATION INSURANCIi PLG.CONTR. LIC.NO. "PLG. /,/P i� v N v
� CI tl'his section need not be completed if the permit is for one TOTAL 1 N
hundred dollars 1$100)or less.) r
V O 1 ecrtily that in the performance of the work I'ur which this per- DTV. MECHANICAL PERMIT FEE SUMMARY
U_ H mit is issued,I shall not employ any person in any manner so as to
Q U become subject to the Workers'Compensation Laws of California.
0.
Date Applicant ALTER OR ADD TO MECH. 5 BUILDING
} W NOTICES TO APPLICANT: 11,after making this Certificate of Es
F Z_ emptiou,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply withFEE
.
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C .) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER1 C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WIT UCT) 5.00
the perfonnunce of the work for which this permit is issued(Sec. MICROFILM
3097,Cis CI HEATING UNIT(T 100,000 B.T.U.) 8.00
s N
Lender' "m v t��
Lender's Addle HEATING UN OVER ER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that I have read this application and stale that the above V ENTIL ON FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING (� /
ordinances and stale laws relating to building construction, and BOILE -CC)MP(3 H.P.Or 100,000 B.T.U.) 6.00 I V
holly authoricu representatives of Ilii, city to enter upon the 1 v
nbovomenlioned property for inspection Purposes. B ER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of 41SC.- REFER TO ORD.
Canicula. against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 AX
may in any way accrue against said City in Consequence of the
of this Permit, ECH.CONT, UC.NO. MECH.
_19 ,.. TOTAL TOTAL <1
at ¢a Contralto[ ate
INSPECTOR COPY
APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE.BALL POINT PEN ONLY
B111 LDI NG PROJECT I DENTI FICATION PERMIT NUMBER
BUILD! APPLICATION & PERMIT '
A°DR ° _ 8477
BUILDING -.ELECTRICAL PLUMBING-MECHANICAL
OWNER.S - 3 x = g q P :- $ T S 1 x g M lk $.'rs'$`$ t j Y 4 PLAN CHECK VALIDATION
AME - OTV. s e " , ELECTRICTPERMITv "$ FEEj`
CCISPPHONE
c TRACTOR'S OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
LIC.No. LIGHTING FIXTURES 10.00/1.00
MIlITAECTORS - APPLIANCES-RESIDENTIAL 4.00
ES
huPONE PANELS 10.00 DATE OF APPLICATION.
DR PANELS (OVER 201)AMP), . 20.00 PLAN CHECK FEE P.C.No.
ENGINEER' r
LIC.No. .SIGNS TRANS. 3,00 -
ARCR.SREna - SPECI AL CIRCUIT - 5.00 P_P);Bp(Ir VALIDATION
ARCH.OR �1�FIfI
ZIP TEMP.METER OR POLE INS. 20.00
ADDRESS .MOTORS SEE FEE SCH.
ADDRESS it '!4
SERVICE CHANGE 20.00 - wf�
w
,02 LICENSED CONTRACTORS DECLARATION , TEMP,POLE 30.00 �1I,�Cu110(�ary
< L,u I hereby affirm that I am licensed under provisions of Chapter.9 ��"' ISSUANC ATE
,HA z n (commencing with Section 7000)of Division 3 of the Business and - SLUG. ELECT. PLG. MECH.
r w i Professions C'e�g a y1 my license is in full fo - -
z o m- License las�s.--�N��p��,b�e,Nom er,
om r o Dale�on[racl `
a m 4El
BUILpINGjPERMITa.$s:8;p
Ie ¢ a OWNER-BUILDER DECLARATION
u, U t a`` INF°ORMATION„c'' } "
Boa MISC.- � REFER TO ORD
X ra LL w I hereby affirm that 1 am exempt from the Contractor's License
uo¢ Law for the following reason. 7031.5,BusinessandProfessi°ns PERMIT ISSUANCE VALUATION , $/FT.
H N as-a' 10.00
Code',Any city or county my which requirese permit to is issuance,
c alter,
¢ ¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC.
wO LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
$ he is licensed pursuant to tine provisions of the Contractor's License
r z i Law(Chapter 9(commencing with Section 7000)of Division 3 of they •".t - q` P' R
4 o Business and Professions Code)or that he isexempt therefrom and QTY.. PLUMBIN&PERM IT , } # FEE; G
¢ I_ the basis for the alleged exemption.Any violation of Section 7031.5 [ a ; ' `, ` " '$ STORIESYPE CONS R.
u3 � by any applicant fora permit subjects the applicant macivil penalty ALTER-DRAIN&VENT-WATER (EA.) 5:00 '
of not more than five hundred dollars($500).): '
❑- I,as owner of the property,or my employeeswith wages as BACK F LOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and ProfessionsDRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's Licensc Law does not apply town owner of I
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACR AGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-11NC.40UTLETS 6.00
ments are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA,) 2.00
/ builder will have the burden of proving that he did not build or in, BUILDING Lu
prove for purpose of sale.): INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB
❑ I,as owner of the property,am exclusively contracting with - 10
licensed contractors to construct the project(Sec. 7044,Business LAWN SPR IN KLEfl$-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to ani owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts foisuch projects with a comracloos)licensed pursuant to SEWER-SANITARY-STORM EA.200ft)10.00 .
the Contractor's License Law. ' TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 6.00 '
reason
Owner Date vWATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION. WATER TREATING EQUIP. 5.00
hereby affirm that Lheve,a certificate of consent to self-Insure, '
or a certificate of Workers'Compensation Insurance;or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,
PoNo. Comp
0 gr0(JVd�,��.V�
Certified copy is hereby urnsshe' dFIRE SPgINK ENERGY T-29
❑ Cert 'ed coo ry"is tde t the mty spection division.
ZZO Applicant-t�p1'L)E}V 'SS-��• MISC.- REFERTO ORD. Y,[:] N[ .Y ❑ N❑
~ H PERMIT ISSUANCE 0
Ud - CERTIFICATE COMPENSATION
INS FROM WORKERS' I FLOOD ZONE' A.L.U.C.
W >_ COMPENSATION INSURANCE PLG.CONTR. - LIC.N0. PLG. /
CL O (This section need not he completed if the permit is for one TOTAL 11f Y NY ❑ NE]
::I Z hundred dollars($100)or les,,)
0' 1 certify that in the performance of4jic work for which this per- - S a ' > f"? z s .a FEE SUMMARY tt, "M
LL F mit is issued,I shall not employ any person in any niannor so at to QTY: ' ' MECHANICAL PERMIT, . $ 3 E; 1 t ' r x N7arB'
O become subject to the Workers'Compensation Laws of California.
i Date Applicant ALTER OR ADD TO MECH. 0 BUILDING
>_ w NOTICETOAPPLICANT: If,after making this Certificate of Ex- -
F Z emption,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 suc[I provisions or this permit shall be deemed revoked; AIR HANDLING UNIT(TO 10,00D .M) 4.00
CONSTRUCTION LENDING AGENCY' AIR HANDLING UNIT(OVER C.FM.16.00 SEISMIC FEE -
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WI DUCT) 5.00
the performance of the work for which this permit is issued(Sec. 'MICROFILM
3097,Civ.C.). HEATING UNIT(X100,000 B.T..U.) 8.00
Lender's Name��"a�- HEATINGU (OV ER 100,000 B.T:U.19.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTIL ION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING-
f� ordinances and state laws.relaling to building construction, and BOIL -COMP(3.H.P.or100,000B.T.U.) 6.00
I hereby authorize representafives,of this city to enter"upon the (Over 100,000 BTU(SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes. BLER-COMP
(We) agree to save, indemnify and keep harmless the City of ISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 1000 CONST.TAX
.
may in any way accrue against said City in consequence of the '
of this permit .y MECH.CONT., LIC.NO. MECH.
roTAL TOTAL
tore of plican Contractor Date
OFFICE COPY