8304 ARPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
SOLOING APPLICATION & PERMIT
ADDRESS 8304
p 00 7P.NEAI.s G 1d' BUILDING -ELECTRICAL-PLUMBING-MECHANICAL '
DWNER's PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
. o"vArrrI PHONES 6 PAID
NOMEUTLETS-SWITCHES-RECEP /1.0
'-"NS 451-EC' LOCNO LIOZ00 LIGHTING FIXTURES 10.00/1.00 MAR 2
nooe[ss aoR's PPLIANCES-RESIDENTIAL 4.00 1985
3 N. C-Ed-rM 1- P..NE379- 6103 PANELS 10.00 - I TION
OR PANELS (OVER 200 AMP) 20.00 N P.C.NO.
ENGINEER
LIC.NO. ISIGNS TRANS. 3.00
ARCH,OR ENG. PERMIT VALIDATION _
ADDRESS SPECIAL CIRCO 5.00
ZIP TEMP.M OR POLE INS. 20.001
AVVLICANT'E
ADDRESS MOTXS SEE JEE SCH.
SPIKVICE CHANGK A 20.00
woo LICENSED CONTRACTORS DECLARATION EMP.POLI tfif y 30.00
<L,L, I hereby affirm that I am licensed under provisions of Chapter 9 �.
Q u (commencing with Section 7000)of Division 3 of the Business and ISSUANCE DATE
H 2 Professions Code,and my license is in fall force and effect BLDG. EL CT. PLG. MECH.
❑ ❑
Z O y - License Class oNumber
i
9 m H�
DateCnntramor �
¢ 2 w a OWNER-BUILDER DECLARATION BUI D NG PERMIT
w- 0 a ° I FORMATION;
g LL y I hereby affirm that I am exempt from the Contractor's Lice s,, MSC. REFER TO ORD '
OL o ¢ Law for[he following reason.(Sec.703 1.5,Business and Professi ns vgwATION SOFT.
- w PERMIT IS CE
Ew02 Code:Any city crecunly whichrequiresapermitloconstruct,al q
is so improve,demolish,or repair any structure,prior to its issuance,aELEC.CONTR, LIC.NO. T ELEC.
mLL requires the applicant for such permit to file a signed statement th TOTAL3�
X he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
H m r Law(Chapter 9(win me ncing wi h Sect ion 7000)o f Division 3 of the - x 1
i 4 o Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ H $ the basis for the alleged exemption.Any violation of Section 703L5 ToRIES PE CONSTR.
i ; - by any applicant fora permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER IEA.) 5.00
of not more than five hundred dollars(5500).):
D I,as owner of the property,or my clnployces with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure is not O GR UP, R B. ITS
intended or offered for sale(Sec. 7044, Business and ProfessionsDRAINS-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 S.OI) sD.FT.FLODR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
mensarenotintendedorofferedforsile.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner"
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND PB Omer
❑ I,as owner of the property,am exclusively contracting with �'
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 gSSESSOR gcEL NO.
El 1:1
and Professions Code:The Contractor's License Law dues 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 contraclor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
❑ lam exempt under Sec..,B.&P.C.for this
reason WATER HEATER W/VENT 6.00
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 ofconsent to self-insure,
ar a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy hereof(See.3800,Lab-C.).Y (J(� _LY.���
PolicyNo. Com an _lam
O Certified Copy is heathy(uritis FIRE SPRINK ENERGY T-24
z 2 O ertified is filed wit the city ins bon Division. -
F O 2phe,I I REFER TO ORD. Y [] NC] Y ❑ N[]
CC y CERTIFI 'ATE OF[EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.Lu.C.
W CI (This section need not beTcompleted ION ll(het-permit is for one PLG.CONTR. LIC.NO. TOTAL Y[:1 NE] ' Y[D N�
ANC
CL CI
=) 2 hundred dollars IS 100)or,less.)
U O 1 certify that in the performance of the work for which his per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U not Is issued,I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
a nota Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ m NOTICE TO APPLICANT: If,alter making this Certificate of Ex-
F.. ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK-
provisions of the Labor Code, you most forthwith comply with U FEE 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 10100011F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
he performance of the work for which this permit is issued ISec. MICROFILM
3097,Civ.C.Y - HEATING UNIT(TO 100,000 B.T.U.) 8.00 1100
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that l have read his application and shte that the above VENTILATION FAN (SINGLE) 4.00
information isstatecorrect, I agree to comply with all city and county BOILER-COMP(3 H.P.Dr 100,000 B.T.U.) 6.00 PLUMBING
ordinances and slate laws relating to building construction, and
hereby authorize representatives of this city to enter upon the
shove-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL+
1
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST-TAX
may in any way accru 'agmtea said City in consequence of the PERMIT ISSUANCE 10.00
gmn,in O Ih is permit A MECH.CONT. LIC.NO. MECH.
�. 3-Zb-$� TOTAL TOTAL D,
\ Slgnat eof AP
ph ant/Contractor Uafe
OFFICE COPY