3831 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
' BUILDING PROJECT IDENTI FICATION
P IT NUMOER
f SODDEN= � APPLICATION & PERMIT r�Q n�
�4"CkVA BUILDING
-,ELECTRICAL-PLUMBING-MECHANIC JUJ
OwNEWa " PLAN CHECK VALIDATION
NAME
M•r, 01e�g CITY, ELECTRIC PERMIT FEE
11� V` PRONE '-146-
CONTRACTORS '
rvAME ( UTLETS-SWITCHES-RECEP 5.00/1.00
Q. 6 vY1 eko.A,v E_ LIC,No. 40 Ilia LIGHTING FIXTURES 5.00/1.00
ADSctoRs
DRESS - APPLIANCES-RESIDENTIAL 4.00
r uG, Uq�tAeA, . PHONE Iett'Z f"I6 PANELS 5.00 DATE OF APPLICATION
ORflCHITECTN SIGNS 6.00 PLAN CHECK FEE P.C.NO.'
ENGINEER
LIC.No. .SIGNS TRANS. 3.00
AENG. PERMIT;6Vf.IDATION
ADDRESS RC" OR SPECIAL CIRCUIT 5.00 AA i
ZIP EMP.METER OR POLE INS.. 15.00
ADDRESS MOTORS SEE FEE SCH.
C SERVICE dITANG9 10.00
oo LICENSED CONTRACTORS DECLARATION - u4soQ ewi U I hereby affirm tio
hat I am licensed under provisns of CImPI,r 9 - C1p5LANCE DATE
H f n (commencing with Section 7000)of Division 3 of the Business and BLDG. E E T. PLG. -MECH.
F w Professions Code,and m license is in full force and ffefl. ❑ ❑ ❑
2 0 a- License Cl C-" Lic.Number "CON-66%
-
Dale Contractor E-r-
Qy L
¢ ¢ ¢ OWNfi R-BUILDIiR DECLARATION BUILDING PERMIT
¢ w uIA INFORMATION
X ;e N 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u o j Law for the following reason,(Sec,7031.5,Business and Professions VALUATION S/FT.
_ g PERMIT ISSUANCE 6.00
Code:Any city or county which structure permit to construct,alter,
QQ Q 0 improve,demolish,or repair any SINCtnrl',prior t0 VS IrruanC0.aI50 ELEC CONTR.' - LIC.NO. ELEC.
i Wmµ Contractor's
the applicant for such permit to file a signed statement that TOTAL ✓t� PERMIT TO
he is licensed pursuant to the provisions of the Contrlcs's Licensee
sir\ Low(Chapter 9(commencing with Section 7000)of Division 3 ofthc r
¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
w. xby any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 4.DD
of not more than five hundred dollars($500).1:
❑ I,as owner of the property,or my employees with wager as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their Sole compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 S0,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
men9xrenot intended oroffered for sale.If,however,the building GAS-EA.SYSTEM-l1NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVBUILDING 4 (EA.) 1.00 BLOIUSE
builder will have the burden of proving that he did not build or im- RES IND CON
PB Ome,
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
Elas owner of the property, El 1:1 1:1
licensed
contractors to construct the
exclusively contracting with ❑ ❑project La 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL No.
and Professions Codec The who
builds o License s til does not apply "
0 an owner of property who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contract for such Proscar with a confinemRsl licensed Pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA,200ft/6.00 TRACT No. PARCEL NO.
❑ lam exempt under Sec. ,B.&1'.C.for osis WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.OATE ACC,FILE NO,
WORKERS'COMPENSAT10N DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a Certificate of 11 to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lah,C.).
Policy No. Company
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z ZClCertified copy is filed with the city inspection division.
0 Applicant MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
~ rn PERMIT ISSUANCE 6.00
LU CERTIFICA COMPENSATION
ION EROMWORKERS' FLOOD ZONE A.L.u.C.
IJJ 1 COMPENSATION INSURANCIi PLG.CONTR. LIC.NO. PLG. '
CIL:1 Z (This section need not be completed if file permit is for one TOTAL Y E] N01 Y ❑ N❑
I u ndred dollars(S 100 l or less.)
0O I certify that in the performance of the work for which this pery OTY. MECHANICAL PERMIT FEE FEE SUMMARY
.mit is issued,I shall not employ any person in any Immne,sn as to
become bb t to the Workers' sm,i Las c4�('ulilornia.
U w Datc Applicant x �f" 7 .."_Sri BUILDING
a - ALTER OR ADD TO MECH. 4.00
} to NOTICE APPLICANT: II,after mu mg this Certificate of I's
? emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 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 10,000CF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE '
I hereby affirm that there is a construction funding agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ C.) 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 8�0
I certify than I have read this application and state thin the above VENTILATION FAN (SINGLE) 3.00
information n correct. I agree tog to b with all city and county -PLUMBING
ordinances and sate Taws relating to building construction, and BOILER-COMPI3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep Ivories, the City.1 MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
• o"of 's permitMECH.CONT. LIC.NO, MECH. ^�
TOTAL 6l/
B 3 TOTAL
Signature of Applicant/Contractor - f to
OFFICE COPY i
a