8347 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
.✓BU I LDING PROJECT I DENTIFICATI ON - PERMITNUMBER
BUILDING APPLICATION & PERMIT 8347 n
ADDFCS - L� I
ID2.ISi OZ6 (� 'BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER"a vD OPLAN CHECK VALIDATION
rvnm4 7 QTY. ELECTRIC PERMIT FEE
• vuoNE- � -
NOM1FRAcrOR's UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No, fJ LIGHTING FIXTURES 10.00/1.00
ACCRUES s CrUAcrons Ub APPLIANCES-
RESIDENTIAL 4.00
3S PNONE O- 8 PANELS 10,00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.06 PLAN CHECK FEE P.C.NO.
OR
O
ENGINEER
LIC.NO, SIGNS TRANS. 3.00
ADDRESS emG. SPECIAL CIRCUIT 5,06 PERMIT VALIDATION
ZIP ITEMP.METER OR POLE INS. 20.00
APPLICANT sADOR _/ ZL _A .` MOTORS SEE FEE SCH.
` SERVICE CHANGE 20.00 q�
woo LICENSI>U CON'T'RACTORS Df:CLAR TION TEMP.POLE 30.00 �7p/
¢u I hereby affirm that I am licensed under provisions of Chapter 9 I55 E ATE
H Q oAi (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. R.G. MECH.
r- z Professions Cod and 'cense is in full force an effec. ❑ ❑ ❑
z O y - License Class Lie.Number
4 m w Date�7--X5 Contractor
E BUILDING PERMIT—
OWNER-BUILDER DECLARATION INFORMATION
w0
LL y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION $/FT.
u 0¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Hyo Code:Anycily orcounty which requires a permit to Construct.alter,
ne to¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO, ELEC.
so
0 u requireS the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w mhe is licensed pursuant to the provisions of the Contractor's License
H z
Asa he
9(commencingwilh Section 7000)of Division 3 of the
Bustness and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ; $ by any applicant for IT permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5,00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or 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,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 ,00 rl 0 sQ.IT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintended or offered for sale.If,however,file 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 no[build or im- RES IND CON PB Omer
prove for purpose of sale.). • INDUSTRIAL WASTE INTER. 30.00
❑ I,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 iLAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects with a contractors)licensed puomant t0 s SEWER-SANITAR V-STORM EA.200ft/1�M ¢T�
the Contractor s License law. Q Y•w0 -UV TRACT NO. PARCEL NO.
❑ I am exempt under Sea ,B.&P.C.Iia alts WATER HEATER Of y.OD6,W 37-6-t
reason
Owner Date WATER SYSTEM 51W6U ACC.DATE ACC.FILE NO.
WORK E RS'COMPENSAT ION DECLARATION WATER TREATI UI .� 5.00
I hereby affirm that I have a Certificate of consent to self-insure.
or a certificate of Workers Compensation Insurance,or a certified ZONING ENG.SITE NO.
Copy lhereo(�(S3gp ).
Policy No�•_'D]=f 61 Zr/y FL4M.nWk�lf NwIry
0 ❑ Cerfifiedcopyisherebyfurnished. / FIRE SPRINK ENERGY T-24
Z Z ❑ Certifi•d opy fIlei Ith the t Inspects n rvlsmn.
O Applicant I�� v+�'s -.J�c�-F•�•-t-1 MISC.- REFER TO ORD. l Y ❑ N❑ Y ❑ N❑
� N CERTIFICATE 01'EXEMPFION FROM WORKERSPERMIT ISSUANCE 0 t�,6� FLOOD ZONE A.L.u.C.
LOU > COMPENSATION INSURANCE P .CONTR. LIC.NO. PLG.
CL 0 (This section aced not be cOmplemd i(file permit is (or one k h (p(pl TOTAL 2.�—Z.�'U Y❑ N❑ Y❑ N❑
::) Z hundred dollar,IS 100)or less,)
U O 1 certify that in the performance of the work for which this per- QTY. MECHi1 ICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner SO as to
O become subject to tine Workers'Compensation Laws of California.
a Date Applicant ALTER OR ADD TO MECH. 5.001BUILDING
} N NOTICE TO APPLICANT: IL after making this Certificate of Ex-
h Z coquina,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of lite Labor Code, you must forthwith comply wilh FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000GF.M.) 4.00
CONSTRUCT ION LISNDING AGENCY AIR HANDLING UNIT(OVER 10DWC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
0th performance of the work for which this permit is issued(Sec. MICROFILM
3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name C -/T-- HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Addre�`Q p- �'* a
I certify that I have read this application 8'SZa Yha'LTRs above VENTILATION FAN (SINGLE) 4.00
information is correct.1 agree to comply with all city and county PLUMBING Q-O
ordinances and state laws relating to building construction, and BOILER-COMPI3 H.P.of1OO,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the 601 LER-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.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
gra i UI'(his permit ' MECH.CONT. LIC.NO. MECH.
_5� TOTAL TOTAL
Sig lure t tAtIplicant/Contractor Date
OFFICE COPY