8489 . rrLIL.HI\lI IU TILL IN INFURMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BADDRESS _ APPLICATION & PERMIT
ROORE55u 8489
/ 9 9)q IE, /([ BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S
�'�_ `,i +"w Y,.r r: .+el PLAN CHECK VALIDATION
S-Feve zfi4KIC� PHONE Ory' ELECTRIC'I RMIT': .FEE".`
• CONTRACTOR'S
NAME s CSU C-3(oOUTLETS-SWITCHES-RECEP 10.00/1.00
E/-70A/ S Odin b„6LIC.NO. . 6 �' A■7 LIGHTING FIXTURES 10.00/1.00 c
CONTRACTOR'S
ADDRESS egA?6e0 APPLIANCES-RESIDENTIAL 4.00 APR
919
vsIDN �j�Q PANELS
4R;--1. 10.00 DA'PAIL AP L$CATION
OR PANELS (OVER 200 AMPI 20.00 C�K4ALic6l§-cK PEE P.C.NO,
ENGINEER el IJP U1gF{EEEwN�
ARCN.OR ENG. LIC.NO, SIGNS TRANS. 3.00
ADDRESS SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 /
AE
ADDDRDRESSSS MOTORS SEE FEE SCH. 000
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
< u I hereby from that I am licensed under provisions of Chapter 9
N a i (commencing with Section 7000)of Division 3 of the Business and ISSUANCE DATE
H 7 2 0
Prate EC e, my license is in full for 6e �f BLDG. ELECT, PL MECH.
is o = License la _ Lic.Number {b7 vt ❑ ❑ ❑
H w Date • Contractor
¢ Y s BUILDI PERMIT
M m w OWNER-BUILDER DECLARATION Arw I
Z
;`y I hereby affirm that I am exempt from the Contractor's License MISC.- gEFER TO ORD :"INFO MATION
HLLoj Law for the following reason,ISec,1031.5.Businessamd Professions PERMIT ISSUANCE VALUATION
E "i Code:Any city or county which requiresa permit to construct,alter, 10.00
5 ¢ FO improve,demolish,or repair any structure,poor to its issuance,also ELEC.CONTR. LIC.NO. _ ELEC.
- p Ic requires the applicant for such permit to file a signed statement that TOTAL
A w he is PERMIT TO
licensed pursuant m Ne provisions of the Contractor's License
HZQ Lw(Chapter 9(commencing with Section 7000)of Division 3 of the .
Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT -FEE;
a =$ the basis for the alleged exemption.Any violation of Section 7031.5 -
a- 3 by any applicant for a permit subjects the applicant toa civil penalty STORIES TV E CONSTR.
Of not more than five hundred Milani(S500),I, ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 1,as owner of the properly,or my employees with wages as
their sole compensation,will do the work,and the structure is not BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
intended or offered for sale(Sec. 7044, and
and Professions DRAINS-FLOOR, F.ARE
Code:The Contractor's License Law does not apply to an owner of A,COND. 5.00
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP
himself or through his own employees,provided that such Improve. F10KOOR AREA TOTAL ACREAGE
ments are not intended or offered for sale.IL however the building GAS-EA.SYSTEM-1 INC.4 OUTL x.98 P
• or vn provement is sold within one year of completion, the owner
-
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
prove for 1,as ownerose
of(he.1. INDUSTRIAL WASTE INTER. 30,00 REP) I❑ CON PIS❑ O❑,
❑ 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
and Professions Code:The Contractors License Law does not apply ASSESSORS PARCEL NO,
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 contractoor)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.20
❑ I am exempt under Sea ,B.&P.C.for this - TRACT N0. PARCEL NO.
reason WATER HEATER W/VENT
Owner Date WATER SYSTEM
WORKERS'COMPENSATION DECLARATION ACC.DATE ACC.FILE NO.
WATER TREATING EQUIP. 5.00
I hereby ar.of that 1 have a certificatention in consent or self-insured
or a certificate herof Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy Iherc iWO,Lab,C.1
Policy No. ompany/' � D�/!10`,mon(
0 M Certified copy is hereby furnished.
Z ❑ Certif cD1� is ed with the city inspection division. FIRE SPRINK ENERGY T 24
FO Applicant .J� MISC.- REFER TO ORD.
LO CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE
W COMPENSATION INSURANCE PLG.CONTR. FIopD ZONE 4.L.u.C.
d O LIC.NO. PLG
(This section need not be completed if the permit is for One TOTAL Y N� V ry�
U O .Icertify
hundred dollars IS 1the Pe less.) _
I certify that h the performance of the work for which this per, + FEE:SUMMARY•LL I-U mit is issued. I shall not employ any person In any manner so as to O�• MECHANICAL PERMIT - FEE'
O W become subject to the Workers Compensation Laws of Califomia. - -
W Date Applicant ALTER OR ADD TO MECH. 5,00 BUILDING
} to NOTICEtion.TO APPLICANT: If,after making this Certificate sa ion
f- Z motion.Youyou should become subject to the forthwith
Compensation APPLIANCE
suprovisionsh ri io the Labor Cade, you,must forthwith comply with 5.00 PLAN CHECK
U such provisions or this permit shall bo deemed revoked. AIR HANDLING UNIT(TO 10,OODQF.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IO,000C.RM.) 6,00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
tire performance of the work for which this permit is issued(Sec.
3097,Civ C.). HEATING UNIT(TO 100,000 B.T.U.) 9.00 MICROFILM
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county
Ordinances and state laws relating to building construction, and BOILER-COWP(3 H.P.Or 100,000 B.T.U.) 6.00 PLUMBING
•hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP IOver t00,000 BTU)SEE FEE SCH. MECHANICAL
h
(We) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10 00 CONST.TAX
grand lh
y _ MECH,CONT. LIC.NO. MECH. -
'Ap rorAL TOTAL (n/
Signature of plicant/ConractoT D
Apale ,(
OFFICE COPY 000