8434 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENT]FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADD E ,�/
E Vf GW C Q - BUILDING—ELECTRICAL—PLUMBING—MECHANICAL 8434
OWNEP(6 PLAN CHECK VALIDATION
NAME /�[•`, .1 cU,pFA-ri A10 PAP-1-AE-AZ 6N: ELECTRIC PERMIT FEE
RQSVEENDPHONE
•
COME
I i
NM�EE,, 4Sv � I,A7�lAsc/q-P UTLETS•SWITCHES-RECEP 10.00/1.00
CONTRW/ CLY"�tQS LIC.No. r �3 LIGHTING FIXTURES 10.00/1.00
ADOREACTOR'6
ApDRF"]$�� 76 7�RQA' SELLA /`} E PPLIANCES-RESIDENTIAL 4.00
1 t feu/ a PHONF. 6?'57.f 7 PANELS " 10.00 DATE OF APPLICATION
ARCIgTECT tl
ORi AlU LL. ?�3$7 PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENG' SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCH. _
SERVICE CHANGE 20.00
W w LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
W D u I hereby affirm that I um licensed under provisions of Chapter 9
vwi ISSUANCE DATE
(commencing with itCTIDI 70se I of full
3 of the Business and BLDG. ELECT. PLG. MECH.
H y z Professions Code,,,,ppnd license is in full(once and efPoc{{. 3 ❑ ❑ ❑ ❑
z0 0 In G License Cle C%' LIC.Num be 3S�-•�3
H w Date Contractor
Q : IJ
¢ a w¢ OWNER-BUILDER DECLARATION BUILDING PERMIT
0 A D INFORMATION
'x ; I hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD
u,'11 .
0 et Law for the followingreason.(Sec.7031.5,Businessand Professions VALUATION S/FT.
Hw PERMIT ISSUANCE 10.00
I w> f Code:Any mulish county it any reqstructure,
u tune permit prior
o its issuancur ete,
,iter
also
e IC ¢ O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC,N0. ELEC.
i E O LL requires the applicant for such permit to file a signed statement that TOTAL
w$ he is licensed pursuant to the proPERMIT TO
visions of the Contractor's License �
HiQ
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe �yl—A
r
i 0 Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ H $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d ; by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN&VENT-WATER (EA.)
of not more than five hundred dollars($500).):
O I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 4:00 OCC.GROUP HES.UNITS
their sole compensation,will do the work,and the shoot ore is not
intended or offered for sale (Sec. 7044; Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. ARC
Code:The Contractor's License Law does not apply to an owner of
Property who builds or improves thereon,and who does such work FIXTURES-PER TRAP SO.FT.FLOOR AREA TOTAL ACREAGE
himself re of rote his own employees.provided 01st such improve-
mentsarenotintendedor employees,provided
that such
building GAS-EA.SYSTEM-1INC.4OUTLETS ArW
or Improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose o1-sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
O 1,as owner of the property,am exclusively contracting with ❑ Cl ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractorts)licensed pursuant to SEWER-SANITARY-STORM EA.200f0.00
the Contractors License Law. u-1TRACT NO. PARCEL NO.
O I am exempt under See,—,IL&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner Dale WATER SYSTEM ACC.DATE ACC,FILE NO,
WORKFRS'COMPENSATION DECLARATION WATER TREATING EQUIP.
1 hereby affirm that I have a certificate of consent to self-insure,
or a certificate of
oof,3Wgorkers'Compensation Insurance,or a certified ZONING ENG,SITE NO.
Pollcthere N�Df Spc Co Lab.CJ- 0X1 r 7s
y Company_ lOYt7es-F'
O ❑ Certified copy is hereby furnished. FIR,E SPRINK ENERGY T-24
Z Z Certifie py is Bled wit to city inspection division.
� 0 vphcanl MISC.- REFER TO ORD. Y❑ N❑ Y ❑ No
OL LO CERTU°ICATE OF -,XEM TION PROM WORKER$' PERMIT ISSUANCE 00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLO,
CIL 0 (This section need not be completed if the permit is for one TOTAL /yo,- Y❑ N❑ V❑ A,[3
=) Z hundred dollon(SIDD)o,less:)
U 0 1 certify that in the performance or the work for which Ibis per QTY MECHANICAL PERMIT' FEE FEE SUMMARY
ly F mit is issued,I shall not employ any person in any manner ao as to
Ow become subject to the Workers'Compensation Laws of California.
Q. Dale Applieanl - ALTER OR ADD TO MECH. 5.00 BUILDING
>_ N NOTICE TO APPLICANT: If,after making This Certificate of Fx-
F emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
Provisions of the Labor Code, you must forthwith comply with(� FEE such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO l0=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construclimi 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.). HEATING UNIT ITO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address - HEATING UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
Icerlify mal l have read this application and slate that flueabove VENTILATION FAN ISINGLE) 4.00
information is MP
correct 1 agree TD comply with all oily and county PLUMBING
ordinances and slate laws relating to building construction, and 801LER-COI3 H.P.Dr 100,000 B.T.U.1 6.00
hereby authorize representatives ec this city es enter upon'[he 'BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
hereby authorize
property for inspection purposes.
(We) agree to Save, indemnify and keep harmless The it 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
gran� f this permit MECH,CONT. LIC.N0. MECH:
E/Ir.� �S - - TOTAL TOTAL
I alum of A Bean/Contmnor Uete
OFFICE COPY