8346 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
,QUI LDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT -
ADDRESS
15- O Z7 Z BUILDING — ELECTRICAL—PLUMBING—MECHANICAL 8346
0-HER S y PLAN CHECK VALIDATION
D
NAME Ir`Y-rV1 OTV. ELECTRIC PERMIT FEE
. PHONE 733-cl 6
NAMERACTona UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO. D LIGHTING FIXTURES 10.00/1.00
DN RADTDR's
ADDRESS APPLIANCES-RESIDENTIAL 4.00
A
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. ISIGNS TRANS. 3.00
ARCH.OR ENG. 6 SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
AODHE55 ,/
3�-' ZIP lsvt EMP. METER OR POLE INS. 20.00
ADDDREDRESSSS P�1®
AMOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 MAR
0 0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 2 1985
a Ur v I hereby affirm that I am licensed mdC,pOrsisions.f Ch.pIc,9 -{Ig5 TE
ve a u (commencing with Section 7000)of Division 3 of the Business and BLDG L T. MECH.
F,w i Professions Cod- and my license is in full force andfe I. ❑ ❑ ❑
z D w — License CI ss Lic.Number
o m w Date— Contractor
¢ y E BUILDING VERMIT
¢ ¢ ¢ OWNER-BUILDER DECLARATION
a a, MISC.— REFER TO ORD INFORM TION
w LL I- 1 hereby affirm that I am exempt from the Contractors License VALUATION $/FT.
F u o a Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires permit to construct,alter,
SE ¢ ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
ar
D IY requires the applicant for such permit to file a signed statement that TOTAL P RMIT TO
n
is
m w he is licensed pursuant to the provisions of the Contractor's License
r z< Law.(Chapter 9(commencing with Section 7000)of Division 3 ofthe
s 4 D Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ How the basis for tile alleged exemption.Any violation of$eel ion 7031.$ 5 ORI S T PE CONSTR.
s ; _ by any applicant for a permit subjects Ore applicant to a civil penalty
of not more than five hundred dollars(5500).): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 1,as owner of the property,of my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 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. 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 3 FIXTURES-PER TRAP -D go FT.FLOOR AREA TOTALACREAGE
• himself or through his own employees,provided that such ice prove.
ments are not intended or offered for sale.If,however,01e building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES we. CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1.as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The 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 contractor(s)licensed pooma t to SEWER-SANITARY-STORM EA.200ft T
the Contractors License Law. .Y L/ TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT �;
rCafan
Owner Date WATER SYSTEM 5.00 -�
ACC.DATE ACC,FILE NO.
WORK 1iRS'COM PENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insuro' ZONING
or a ecrtificate nl'Worker,'Compensation Insurance,at a certified ENG.SITE NO.
ropy thereof(Sec.3 ab.C.).
Policy y FiWwv.DnA' SMM'�n
O Cl Certified copy is hePeby furnished. FIRE SPRINK ENERGY T 24
Z Z Sa Certified c py Is ed wi ti the city in cetipn division. MISC.- REFER TO ORD.
O Applicant_/�: Y ❑ N❑ V ❑ N❑
CC T CER'I'I FICA'rE of EXEMPTION FROM WORKERS' PERMIT ISSUANCE -6D FLOOD ZONE A.L.U.C.
LL > COMPENSATION'INSURANCE PLG. ONTR LIC.NO. PLG, 7�[•�yI_Q'p
d o (This section need not be completed if the permit is for one 2-GG 16 TOTAL CE/ Y E] N❑ Y [:] N❑
0 Z hundred dollars IS 100)or lest.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1— mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers Compensation Laws of California.
111 n DateApplicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If,alter making this Certificate of lix-
F ? enlption,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 such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm thin there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
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.) 8.00
Lunncr's Nana HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Addresx CenLA ELECTRIC
I certify that I have read this application and slate that l�o VENTILATION FAN (SINGLE) 4.00
• infori ation is correct. I agree to comply with all city and County PLUMBING
ordinances and state laws relating to building const Ruction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to eater upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
abovomentloned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of 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 10,00
gra tiag of this perm it. MECH,CONT. LIC.NO. MECH.
_I_� - TOTAL TOTAL
bigmifture of Applicant/ ontractor 1JDate t '�
OFFICE COPY