8903 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLYrw X57
BUILDING PROJECT I DENTI FICATI ON PERMIT NUMBER
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IL ING APPLICATION & PERMIT 8903
OREss /J
99'7 /LOo%!L-10Eu 3 BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S _
NAME PLAN CHECK VALIDATION
=ELECTRIC PERMIT FEE -
C PgonE
CONTRACTORS
9rvAME /A�� OUTLETS-SWITCHES-RECEP 10.00/1.00
7,6,9/ .*vC• �L/"J"� 1(7 NO. / /,S3 LIGHTING FIXTURES 10.00/1.00
CONTRACTORS' APPLIANCES-RESIDENTIAL 4,00
�avr�i7KlCS SY-oS• PHONES _� PANELS . 10.00 DATE OF APPLICATION
OR PANELS
PANELS (OVER 200 AMP) 20.00 - PLAN CHECK FEE P.C.No.
ENGINEER UG NO, SIGNSTRANS. 3.00 Fri
ADDDRESS ENG' SPECIAL CI RCU IT 5,00 FERMI ON
ZIP EMP-METER OR POLE INS. 20.00 D 1 A
ADORE NT'S Al` I r^rI L 19�3�
Aoogsss MOTORS SEE FEE SCH. � I ,,J t�'
60A9 EC _c .1w SERVICE CHANGE - 20.00 -
o o_ LICENSED CONTRACTORS -CLARATION TEMP.POLE �: �!I bn '
wF
30.00 Pertln0
ao pj 1 hereby affirm that I um licensed under provisions of Chapter 9
n (commencing with Section 7000)of Division 3 of the Business and ISSUANCE DATE
r n i Professions Code, nd my license is in full force and c(fe j BLDG. ELECT- P G. MECH.
z O w- License CI ss �"3L Lic.Contractor C y!'
o A - Date ) ❑ ❑ ❑
r m E� 'f' J��6--Contractor - -
rc rt w a OWNER-BUILDER DECLARATION BUILDING• E MIT „
o MISC.- REFER TO ORD INFORMATION",' t"
w ;LL y I hereby affirm that I am exempt from the Contractor's License
u0j Law or the following reason.(Sec.7031.5,Husinessand Professions - VALUATION
wvi Y Y ywhich reyuiresa permittoconstruct,alter, PERMIT ISSUANCE S/FT.
Co e: n cit or count 10,00
K Q O Imdrov tlemoRsh,or repair any structure,prior t0 its issuance-,als LEC.CONTE. LIG-NO.
ELEC.
a W m LL requires t appheant for SIIeh p¢rmlt(O fill¢a>Igned SfaterllCnt t TOTAL T TO
he is liwnse ursuant to the provisions of the Contrnlaoi s ease ER
r z a Law(Chapter wmmencing with Seetlon 7000)of Divis' Sof the - -
F i o Business and Pm stone Code)or that he is exempt refrom:md OTV.- PLUMBING PERMIT` - FEE` -
a [he basis for the aIle -d exemption.Any violation ection]031.5 VENT-WATER STORIES YP CONSTR.
n3 � by any applicant fora rmi[subjects the appli rttoacivil penalty, gLTER-DRAIN&
of not mom than five hu red dollars($500 (EA.) 5.00
❑ I,as owner of the p perry,or m mployees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,wit o the rk,and [he structure is cut OCC.GROUP Flit.UNITS
intended or offered for sale I -c. 44, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License w does not apply to an owner of
property who builds or im pr s t non,and who does such work FIXTURES-PER TRAP 5.60 SO.FT,FLOOR AREA TOTAL ACREAGE
• himself or through his ow mP1oYc provided that such improve-
ments are not intend ed offeredfors .If,however,the building GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement is so within one year completion,the owner- GAS EASYSTEM-OVER 4 (EA.) 2.00
builder will have I arden of proving Ilia a did not build or im- - . BUILDING USE
prove forteJ. INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB -.Oma,
❑ I,ass ow ow r off the property,am exclusive contracting with ❑ ❑ E - ❑ }
licensed co actors to construct the project( ec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Probe ons Code;The Contractor's License Law does not apply t.
IN
an o at of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 6(EA.) 1.00
cont, ,such projects with a mmoctor(s)licensed p ommil to
the Conaxon tractor's License Law. SEWER-SAN ITAR V-STO RM EA.200ft/10.00 i TRACTNO. PARCEL NO.
❑ lam exempt under Sec. ,BABC,for this / WATER HEATER W/VENT 6.00 4�
Owner Date WATER SYSTEM 5.00
ACC:DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a certificate ofcousenl to self-Insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO. -
copy thereof(Sec.3800,LA .). �� -
Policy NoK7Company 9oniE�Rnd SnS .
O ❑ Certified copy is hereby fu niched FIRE SPRINK ENERGY TY4
Z Z ¢Z•Certifetl py is fiJed wnh [ city ins(irdion division.
0 Applicant, .lAzslA 2=�-t-:f MISC.- REFER TO ORD. - Y[] N Y Q N[]
j N CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 /Q a FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG CONTE. LIC.NO. PLO.
4' 0 (This section need not be completed If the permit Is for one _.O' 67eeG /7/.-3 TOTAL� �-C`C Y 'N Y N
D Z no d dollars(SIOO)or less)
U O I cer;subject
in the performance of thew r which this per- QTY - MECHANICAL PERMIT - FEE - FEE-SUMMARW v"
LL H mit is iI, oI employ a on in any manner so as to n
O W becomm Iha ompensation Laws of Culifomia.- -
a Datc mom ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICLICANI': Ifalter making this Certificate of lix-
F-. emptiould become subject In the Workers' ,an
APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with • FEE
V such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT(TO 10MC.F.M.) 4,00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0)000C.F.M.) 6.00 SEISMIC FEE
1 hereby a there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the pert f th --
3097,Civ.0HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender ame
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify That I have read IN,application and stale Him line 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
above-mentioned property for inspection puoses, BOI LER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify rp
emnify and keep harmless tlln City.of MISC:- REFER TO ORD.
Cupertino against liabilities,judg nts, costs and expenses which CONST.TAX
may in any ay accrue against City in consequence of the PERMIT ISSUANCE 10.00
granting of sperm L' } MECH.CONT. LIC.NO. MECH.
a/�do�12�sTOTAL TOTAL
ignature of Applicant/Contractor Date -
OFFICE COPY