8428 To a
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY 6%6d
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
"HANG APPLICATION & PERMIT
Abu Ess AQ/ J?d
_ ..-, r A BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 8428
A OWNER'S PLAN CHECK VALIDATION
NAME
DTV. ELECTRIC PERMIT FEE
5 y(r V PRONE - O
' CONTRACTOR'S
NA OUTLETS-SWITCHES-RECEP 10,00/1.00
® ZK LIC.NO,-/10-,?1/5J S LIGHTING FIXTURES/,),S 1 .
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
//,.ONE 3;j-/cv t/ PANELS 10.00 DATE OF APPLICATION
OARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER -
' LIC.NO, SIGNS TRANS. 3.00
ARCH.OR
RENG. SPECIAL CIRCUIT _ S.00
APPLICANTS PERMIT VALIDATION _
SS ZIP EMP.METER OR OLE INS. 20.00 /� x�•
{ t
AnoREss MOTORSrS
� � EE FEE SCH.
SERVICE CH GE 1 1`"'' 20.00
wo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a U U 1 hereby affirm that I am licensed under provisions of Chapter 9 to, r; V�' "k-2 ISSUANCE DATE
N <"' (commencing with Section 7000)of Division 3 of the Business and BLDG. ELELT. PLG. MECH.
H 0 LA z Professions Code,unA my license i5 in full force and effect /X Tt<rt/S STu 66E ^/ ) ❑ I O ❑
p0 m o License Chau-_< O -Lic.Number .�'l
< T to j Date-=�'�`�-Contractor - r�F1 ,O/�� &V 9.q"`C/S oa+.
a: Q w< OWNER-BUIhDER UECLA RA'f10N SW s+Eh x+'�-� BUILDING PERMIT,
U MISC.- REFER TO ORD -INFORMATION,;"
w ;a. I- I hereby affirm that I am from the Contractor's License
H u 0 j Law for the following reason.(Sec.7031.5,Business and ProfessionspERM1T ISSUANCE l,P.pV AO-BB VALUATION $/FT.
Code'.Any city or county which requires a Permit to constmct,alter
GQ Q improve,demolish,or repair any structure,prior to its issuance,also LE'C.IC/O_NTRp. LIC.NO. ELEC.
K m u requires the applicant for such permit to file a signed statement that �E�rxo EV�lS.� CYO a 3) TOTAL$Zo•OD
'' w he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
H z �'
Law(Chapter 9(commencingwilh Section 7000)of Division 3 ofthe (z-ZEz,T
4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE /
W H g the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d3 _ by any applicant fora permit dollars the 0),): and toxcivilpcnalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollar(my eni1:
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 DCC.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 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his Own employees,provided that such improve-
mentsare not intended oroffered for sale.If,however,the building GAS-EA.SYSTEM-l1NC.4OUTLETS 6.00
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 be did not build or im- BUILDING USE
prove for purpose of sale J' INDUSTRIAL WASTE INTER. 30,00 RES IND CON PB Other
r ❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ 0 1:1 0
licensed contractors to construct the project(See. 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 Snell projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec..,BAP.C.for this
anon WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
WORK ERS'COMPFNSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I'have a certificate ofconsent to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof f Sec.3800,Lab.C.)��//'',`. ''''''
Policy No. Company E sJ _,,
O ❑ Certified copy is hereby furmsheJu IC--7( _QO FIRE SPRINK ENERGY T-24
Z 2 'e-Certified 's fi •_tai�e city inspection division. ❑ ❑ ❑ ❑
� O Appli MISC.- REFER TO ORD. Y N Y N
O: to CIi R'fI PICA li Olr IiX1iMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.O.
L COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLGCL .
Z (This section need no, he completed if the permit is for one TOTAL V N� Y N[]hundred dollars($100)Or les$.)
U O.- I certify that in the performance Of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any Person in any manner so as t0
O L) become subject to the Workers'Compensation Laws of California.
CL
Date Applicant BUILDING
} to NO'FICR 1'0 APPLICANT: If,after making this Certificate o1'Ex- ALTER OR ADD TO MECH. 5.00
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
U Sash provisions Or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that 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
Lender's Name HEATI NG UN IT 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that l have read this application and state!list the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree t0 comply with all city and County PLUMBING
ordinances ,,it 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 Purposes.is city to enter upon the
above-mentioned property
forinspection BOILER-COMP(0.,100,000 BTU)SEE FEE SCH. MECHANICAL
.\ h
J (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
granting of 's permit. MECH.CONT. LIC.NO. MECH.
^�' te 8,3•� TOTAL TOTAL
tgnamre Applicant/Contractor Uate
OFFICE COPY