C 8501 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDINGPROJECT IDENTIFICATION . PERMIT NUMBER
BUILDINA .APPLICATION &'PERMIT
ADDRESS ' • 8501
D STod.N TO +�ONEsTPM BUILDING-ELECTRICAL-PLUMBING-MECHANICA
OWNS 'a q y z PLAN CHECK VALIDATION
NAME _ p ELECTRIC.PERMIT a " FEES`
•
-Tit CO ` PHONE 77 _ISJJ .
CONTRACTORS C-2 - OUTLETS-SWITCHES-RECEP 10.00/1.00
'TY .L i.774rd uc.ND.30//OY LIGHTING FIXTURES '10.00/1.00
ADTRons - APPLIANCES-RESIDENTIAL 4.00
CONTRACTOR
ODcARESS /I 1 `l
O AL PHONE J7®/,r�i PANELS 10.00 DATE OF APPLICATION
ARCHITECT - PLAN CHECK FEE P.C.N0.
OR PANELS (OVER 200 AMP) 20,00
ENGINEER
uc.No. . SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS _ SPECIAL CIRCUIT 5.00
- ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS r MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00S--
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 O
a U 'u. I hereby affirm that I am licensed under provisions of Chapter 9 ANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BL CT. PLG. MECH.
r m z Professions Code, and my license Is In full force d effect. - - ❑ ❑
zap License Class-�-21 Lie,Number �o/!s4
Dale_LEQ�LLz Contractor Q$L
wa OWNER-BUILDER DECLARATION _. L GrP,E RMIT;a-a u
0 U MISC.- 'REFER TO ORD ''s R1NFORMAT•IONis &4
w g IL w 1 hereby affirm that 1 am exempt from the Contractor's License
u O j Law for lire following reason.(Sec.7031.5,Business and Professions - A 9/FT.
r - PERMIT ISSUANCE 10.00
Code:Any city or county which raquiresu permit to construct,,also
improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIG NO. ELEC.
a- O rc requires(he applicant for such permit to file a signed statement that TOTAL
v w m a- he is licensed pursuant to the provisions of the Contractor's License - PERMIT TO
Fz < Law(Chapter9(commencing with Section 7000)of Division 3 of Ilia MB✓� Cie,Vli7Va�,f�
4 O Business and Professions Code)or that he isexempt therefrom and DTV. PLUMBING PERMIT FEE .
rc H the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ; by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(8500)J:
❑- I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 ,Oce.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for .to(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 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 he did not build or im- BUILDING USE
Prove for purpose ofsaleJ. - INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,BusinessLAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORSPARCEL N0.
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 such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200k/10.00
the Cmrtractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Ser.--,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner
Data WATER SYSTEM 5.00 " ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a cortilied ZONING ENG.SITE NO.
copy thereof(Sec.3800,lab.C) /�
Policy No. COmpay TfgTC r-14
0 ❑ Certified copy is hereby furnished. 4 O('�( sj 4C 1( FIRE SPRINK ENERGY T-24
Z Z ❑ Certs' d opy is filed with the ci y mspectmn division.
O Applicant(�,L _. 'tiL(..wi1 MISC.- REFER TO ORD. Y N� Y N[3
'X W CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
COMPESION
SU
LL.I > (This section need not be complleted R 'If he permit is for one PLG.DDNTR, LIC.NO. TOTAL V N V N
PUG
CL o
:D Z hundred dollars($100)or less.)
U O 1 certify that in the pedorm ave of the work for which Ods per- CITY' MECHANICAL PERMIT _ ' FEE .r =FEE`SUMMARY
.LL I- mit is Issued,I shall not employ any person in any manner so as to - : >
.Q W become subject to the Workers'Compensation Laws of California.
a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING OR JI
>_ CA NOTICE TO APPLICANT: If,after making this Certificate of Ex- V
F Z emptlon,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 10000C.RM.) 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.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I'agree to comply with all city and county gO1LER-COMP(3 H.P.Or 100,0008.T.U.) 6.00 PLUMBING
ordinances and stale laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP lover 100,000 BTUI BEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
.. (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
m m any way accrue against said City in consequence of the
Ian Bi of(h' permit MECH.CONT. LIC.NO. MECH.
t A '/ TOTAL TOTAL
ature of Applicant/Contractor Data '
OFFICE COPY,