8443 !APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION '- PERMIT NUMBER
mUILJING - APPLICATION & PERMIT 8443 A j
Y ST�vE�S CRed/� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL '
OWNER'S - PLAN CHECK VALIDATION -
-.� "gAMIE 'T ELECTRIC PERMIT ,FEE
CONTRACTOR
P.ONE
NAMQRAcro"s UTLETS-SWITCHES•-RECEP 1&017/1.00
C/p
6 E -G Lic.No: �9 3g LIGHTING FIXTURES 10100/1.00
ADDRESS ro"s APPLIANCES-RESIDENTIAL 4.00
$7PHONE' PANELS - .}B:MO O ^` DATE OF APPLICATION
ARCHITECT
OR
- - PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
O
ENGINEER -
' uc.No. SIGNS TRANS. 3.00 -'
,)DRESS ENG. - SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
'ZIP- ITEMP.METER OR PFAID. 20.00
ADDRESS " - • MOTORS SEE FE_E SCH. I
SERVICE CH - 20.00
w O 0 LICENSED CONTRACTORS DECLARATION TEMP.POLE - -` 30.00
a
to I hereby affirm that 1 am licensed Ruder provisions of Chapter 9 t... I O Cupertino ,Sa ISSUANCE DATE
Nz w (commencing with Section 7000)of Division 3 of the Business and
Z< n Sv BLDG. ELECT. PLG. MECH.
H a v, Professions Cod�ekL mAl3pPy license is in full force anA�••jjjl'le ,3 /-
oCm - 1 License Loss_A,;a.j.(J_Lic Rurtihe. !Q 1_ 82- �� - I �,,
�� DInc Contractor's"•`�'DY�E- /��. � T.CH 1rK✓A- .D
am re BUILDING PERMIT „
¢ a OWNER-BUILDER UECLARA'PION
M o e- u p ,. INFORMATION "
w 3:LL w 1 hereby affirm that I nm exempt from the Contractor's License RD
MISC.r, REFER TO O
LLO¢ Law forthe following reason.ISec.7031.5,Business and Professions VALUATION $/FT.
I- - 'A Code:Any city orcounly which requires a permit m construct,after.
PERMIT ISSUANCE _10.00 D
re a,a p improve,demolish,Or repair any structure,prior to its issuance,also ELEC.CONT". LIC.NO. ELEC. QQ
to
DLL requires the applicant for such permit t0 file a signet(statement that - TOTAL
w $ he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
7
z ¢
Law(Chapter 9(commencing with Section 7000)o(llivision 3ofthe'
4 0 Business and Professions Cade)or that he Is exempt therefrom and CITY. .PLUMBING PERMIT FEE
¢ H $ the basis for the alleged exemption.Any violation of Section 7031':5 STORIES TYPE CONSTR;
by any applicant for a permit subjects the applicant Ina civil penalty
of not mom than five hundred dollars($500).): ALTER-DRAIN& VENT-WATER"(EA.) 5.00 "
❑ 1,as owner of the property,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 sl ructure is not
intended or offered for sale (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 docs such work FIXTURES-PER TRAP 5.00 s0.FT.FLOOR AREA TOTAL ACREAGE
himself m through his own employees,provided that such ibuildi� -
oments am notrimprovemenn(endedor withinrone year .If,however,Otho ower, GAS-EA.SYSTEM-11NC.4OUTLETS 6.00 '
or improvement is sold within proving
of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
PIS builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of saleJ. INDUSTRIAL WASTE INTER., 30.00 RES IND CDN PB other
❑ I,as owner of the properly,am exclusively c ntracting with ❑ ❑ ❑ ❑, ❑
licensed contractors'(,) construct the project(Sec. 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 thereom and who LAWN SPRINKLERS,-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to SEWER-SAN EA.200ft/10.00
the Contractors License Law. TRACT N0. PARCEL NO.
❑ l am exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00 "
reason
Owner Date WATER SYSTEM 5.00 ,-ACL.DATE ACC,FILE N0.
WORKERS'COMPENSATION DECLARATION ' WATER TREATING EQUIP. 5.00 -
I hereby affirm that I have a llrlificate Of consen(to self-insure. ZONING
Or o certificate of Workers'Compensation'Insunvree,or a certified ENG.SITE NO.
„ rr�DoAp�/yyv thereof(Sec 3 aaft,C.). �1 p N ` -r
04
r'LLD Certifiede0py is hereby famished. FIRE SPRINK .ENERGY TQ9
Q ❑ Cc lift opy 4 Iil d lith the city inspection division. MISC.- REFER TO ORD.
Applicant Y ❑ N❑ Y ❑ IN
F us ISSUANCE 10.00
CERTIFICA1'1:01'EXEMPII F O ORKBRS' FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE. PLG.CONTE. LIC.NO. PLG. '
0. 0( This section need not be com fileted if the permit is for one TOTAL Y❑ N❑ Y❑ N
hundred dollars($100)or lust.)
U 0 I certify that in the performance of the work for which this per- QTY. MECI•IANICAL PERMIT FEE iFEE SUMMARY,
LL I- mit is issued,I shot] not employ any,person in any manner so as to - ,
Ow become subject to the Workers'Compensation Laws of California. -
y Date Applicant - BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of lis- ALTER OR ADD TO MECH. 5.00
F 2 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 10XDC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C-F.M.) 6.00 SEISMIC FEE
I hereby affirm that (here 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.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name H EATI N G UN IT(OV E R 100,000 B.T.U.)9:50 3-Q
I-cnder's Address - E ELECTRIC
I certify.that l have read this application and sta"(hat the above VENTILATION FAN (SINGLE) 4.00
information n correct. I agree to comply with all city and county BOILER-COMP(3 H.P.Or 100,000B.T.U.) 6.00 PLUMBING
ordinances and state Paws relating m building,.,,,,,, uc(i0n, and
Immby authorize representatives of this city enter upon the BOILER-COMP.(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes:
(We) agree to save, indemnify and keep harmless (he City of ' MISC.- REFER TO ORD.
CuperInto 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
gr' go (hi rt I.�1 MECH.CONT. LIC.NO, MECH.
TOTAL TOTAL
bignatureo Appbco ont actor Dole
OFFICE COPY -
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