8284 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
B L'DI NG PROJECT 1 DENTI FICATI O' f PERMIT NUMBER
CODING Q APPLICATION & PERMr 8284
aooREss BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
' d/ o - l9!'TU�' v�B� D
p OWNER'S ,VVnCC'lY[T'e.CL PLAN CHECK VALIDATION
• NAME �PQB„'T1N�0 QTY. ELECTRIC PERMIT FEE
T y PHONE
CONTRACTOR
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
LIC.No. LIGHTING FIXTURES 10.00/1.00 I I'y(,/
roNTRAcroR�s PPLIANCES-RESIDENTIAL 4.00
ADDRESSPHONEPANELS 10.00 TE OF APPLICATION
ARCHITECT qq PANELS (OVER 200 AMP) 20.00 PLA CHECK FEE P.C.NO.
O
DR �'ksB '6 f�
ENGINEER
SSOCLIc.rvo 00 SIGNS TRANS. 3.00
ARCH.ORENG. Sr ,� $uMY�t PERMIT VALIDATION
ADDRESS a a�� SPECIAL CIRCUIT 5.00 PAID
ZIP EMP.METER OR POLE INS. 20.00
APPLIC• 'DIIEANT'S
ADDRESS /.30/ -5 /✓1A¢�`� MOTORS CH. Jul_ Z gNfj
Sunil Vole. 9� �� SERVICE CHANGE 20.00 JU Ii19
'02 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 Citi of Cupertino
M u u I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUA E DATE
uaHi<w (contntencing with Section 7000)of Division 3 of the Business and BL G. ELECT. PLG. MECH.
H w z Professions Code,and my license is in full force and effect ❑ ❑ ❑
z o w - License Class Lie.Number
-
2 z w Date-Contractora Y f BUILDING PERMIT
M ¢ OWNER-BUILDER DECLARATION INFORMATION
R
u aHi 1 hereby affirm that 1 am exempt Iritm lire Contractor's License MISC.- REFER TO ORD
.. o a Law for the following reason.(Sec 7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
F Code:Any city orcounty which requires a permit to construct,alter, _
rtso Q O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- DLL requires the applicant for such permit m file a signed statement that TOTAL PERMIT TicO
La m he is licensed pursuant to the provisions of the Contractor's License
H z i
Law(Chapter 9(commencing with Section 7000)of Division 3 of the S a
- a Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Section 7031.5 STORMS TYPE .
3_: by by any applicant for a permit subjects the applicant toacivil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES. T5
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,AR EA,COND. 5.00
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 5.00 SO.FT FLOORAREA TOTALACREAGE
himself re through his own employees,provided stmt such Improve-
that such
building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that h .e did not build or im- R IND CON PB Omer
prw,el rpurpose of salt.). INDUSTRIAL WASTE INTER. 30.00 0 El 11 D
I,as owner of the property,am exclusively contracting with
Ii sed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSOHSPAHCELNO.
and Professions Code:"I'he Contractor's License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
Contracts for such projects with a contnactor(s)licensed pursuant to
the Contractor's License Law. SEWER-SAN ITAR V-STORM EA.200ft/10.00 TRACT
ACT NO. PARCEL NO.
❑ Iamcxcantamder Se .B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner ate' WATER SYSTEM 5.00
ACC.GATE ACC FILE NO.
woRRBRS'COMPNSATION nIiCLnR 10N WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of cotismu to self-instim. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereo f(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPHINK ENERGY T 24
z Z ❑ Certified copy is fled with the city inspection division. MISC. REFER TO ORD.
O Applicant Y ❑ NO Y ❑ NO
CC to CER7'IFICA7'Ii OF FXEMPp1ON FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LL 7 COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG. Y N V N
d 0 (This section ted not he completed If the permit is for one TOTAL
Z) Z hunded dollars 1$100)or lessJ
U O 1 certify that in the performance of the wink I'or which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
mit is issued.I shall not employ oanym Fastin in any manner so California.to
esu d,I to the Workers'Compensation Laws of.herso Sato
Det Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
MAI
ICE 70 APPLICANT: If,after making this Certificate of Ex-
F ? emption,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK /I
provisions of the Labor Code, you must forthwith comply with FEE 7
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
C'ONS'FRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=CF.M.) 6.00 SEISMIC FEE
I hereby affirm Ibis there is a construction lending agency lir EXHAUST HOOD(WITH DUCT) 5.00
the performance o the work for which this emit is issued(Sec. HEATING UNIT(TO 700,000 B.T.U.) 8.00
30mb,'97, s .am N,L � m Q��14,
Lender's Name lF--
Lender's Addrefa'v HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRI
�T^G)i
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
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 harmless the City of MISC.- REFER TO ORD. nQ///��I/7
Cupertino against liabilities,judgments, cast I expenses which CONST.TAX � 1 2
may in any way ace ga sa' ity consequ e I the PERMIT ISSUANCE 10.00 666_1
'ng o is Penni MECH.CONT. LIC.NO. MECH.
J� L TOTAL TOTAL 07
Signature of Appli and ontractor tat G
OFFICE COPY