09830 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
oAPPLICATION & PERMIT BUFLDI NG PROJECT 1 DENTI FICATION PERMIT NUMBER
7j aD,L ,rvG /
ADDRESS ^ -5;Ive{�QD BUILDING -
-2oY3 L. EL
ECTRICAL-PLUMBING -MECHANICAL 09830
OWNEH'$�
rvAME /o O `/e Q� ev'7-- PLAN CHECK VALIDATION
/_ [' P O ELECTRIC PERMIT
FEE
c/o VA✓ ou PHONE�SZ�IOZQ
CONTRACTORS
NAME1 UTLETS-SWITCHES-RECEP 10.00/1.00
elvwj t7LetlViL LIC.NO. ��7�i / LIGHTING FIXTURES 10.00/1.00
AODNDHESCTOR's r �,�2 b8) APPLIANCES-RESIDENTIAL 4.00
I �e 5+ N74 PHONE jjj�PAN E1LS 1U.DQ DATE OF APPLICATION
OR
HLHITECT PANELS (OVER 200 AMP) 20.00 W PLAN CHECK FEE D.C.NO.
ENGINEER
LIC.No, SIGNS TRANS. 3.00
ARCH.OR ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zu, EMP.METER OR POLE INS. 20.00
APPLICANT'$
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
o¢ i
F o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 O C p/
Q o s~j I hereby affirm that I am licensed under provisions of Chapter 9 o G J
2 w ISSU CE PTE
n a uai (commencing with Section 7000)0(Division 3.1 the Business and BLDG. ELECT. PLG. MECH.
H w z Professions Code.and try license is in full 1'or and eif t ❑ ❑ ❑
Zo i m o sense Cla .�I�Lic.Number
m H j Date /4 /- Contractor
M M E
¢ ¢ w ¢ OWNER-BUILDER DECLARATION ,. 'C�i BUILDING PERMIT
o A G INFORMATION
X ; LL m I hereby affirm that I am exempt from the Contractor's License MISC.- U REFER TO ORD
H e. o J Law for the following reason,(Sec.7031.5,Businessand Professions PERMIT ISSUANCE VALUATION $/FT.
wt' Code e.dem y demolish,
countypairwhich
any structure permit o its retract,alter,
0.00
2 ¢ ¢ improve,demolish,or repair any structure,prior to its issuance also ELEC.CONTR. GlIELEC. OV
D u requires the applicant for such permit to file a signed statement that TOTAL3pZ40
PERMIT TO
e w m w he is licensed pursuant to the provisions ol'the Contractor s License
F z rt La.(Chapter 9(commencing will)Section 7000)of Division 3 oflhe Lr
i ea Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ H $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by of[notny the fora permit subjems the applicant roacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(8500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP REB.UNITS
or offered for Lice(Sec, 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,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 re of rote his own employees,provided that such im building
ments Improv meet is sold w thinoffered
on for o lco mpletion the building GAS-EA.SYSTEM-1 INC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner-
builder
wner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
oof will have the burden of proving that he did not build or im- BUILDING USE
Prove for purpose of sale.(. INDUSTRIAL WASTE INTER. 30.00 RES INDCON PS Other
❑ L as owner of the property,am exclusively contracting with ❑ ❑ 0 O ❑
licensed contractors to construe the project(Sec. 7044,Business LAWN SPRINKLERS-1 INN 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-OVE
contracts for such projects with a contractof(s)licensed pursuant to
the Contractor's License Law. SEWER-SAN ITAR V-STORTRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for this WgTER HEATER W/VENTonOwner Dute WgTER SYSTEMACCDATE ACC.FILENOWORKI:RS'COMPENSATIONDIiCLARATION WATER TREATING EQUI
I hereby affirm that I have a cenificete ofconstnl to rel Gineure,
)or a certificate of Workers'Compensate n esu ce,or a certified ZONING ENG.SITE NO.
copy there9):{SeC. $QJ/.Laft,C�j, f- �Qp.yPrNs.
Policy era rfp
O ❑ Certified Copt's •rcby fumisluJ.-F
Z J FIRE BPRINK ENERGY T24
❑ Curti -• opt'-is 'Ic with a ,ty 'nspe ion division.
Applicant MISC.- REFER TO ORD. Y[:] NE] Y [] IN
DL w CERTIFICATE OF H f Mill ION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
UJ COhIPF.NSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
1 D This section need not be completed if the punnet is for one TOTAL Y❑ No Y N�
� 2 hundneddolla,IS 100)or loss.)
U O I certify that in the performance of me work for which"'is per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I scull not employ any person in any manner so us to
O W become subject to the Workers Compensation Laws of California.
y Date ICANIam ALTER OR ADD TO MECH. 5,00 BUILDING
} 0. NO'OCG TO AI'1'LICANf: If,alter making this Certificate of Ex-
F- Z 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 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=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 construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the wo f which this ermit issued ISca MICROFILM
3097,Civ.CJ. P _� HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address7. HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
. I certify that I have read this application and stale that the,bov 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 anter upon the
amen-iertioned property for inspection purposes. 801 LER-COMP (Over 100,000 STU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, vests and expenses which CONST.TAX
may in any way c e against said City i consequence of the PERMIT ISSUANCE 10.00
gr i .pf th" p Li �- MECH.CONT. LIC.N0. MECH.
TOTnL
`Slgnatureo Apph t/Contraetor Date TOTAL
OFFICE COPY