8420 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI DING PROJECT I DENTI FICATI ON PERMIT NUMBER
aulLpl G BUILDING APPLICATION & PERMIT
AOOREss Q O d / �� 8420
.Jl -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'5 PLAN CHECK VALIDATION
N OTY. ELECTRIC PERMIT FEE
I�I PHONE
CONTRACTOR'
NAME Nn d, OUTLETS-SWITCHES-RECEP 10.00/1.00
c UI SO A/ el LIC.No _ry LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S �s. PPLIANCES-RESIDENTIAL 4.00
AGORES
J H R146191 PHONE36� 7 PANELS 10.00 DATE OF APPLICATION
ARCHITE iPLAN'CHECK FEE P.C.NO.
OR WC- - PANELS (OVER 200 AMP) 20.00
ENGINEER ,
uc.No. ISIGNS TRANS. 3.00
ADDDRESS OR ENG' - SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS
MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 ��JJ
, 00 LICENSED CON'fBACfORS DECLARATION TEMP,POLE 30.00 � /�s'
¢ U U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE 6/ATE
y a N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H o z Professions cod it it myy license is in full force'n f t.
Z 0 W License Class_(SJ-L_Lic.Number�1
2 rn r Date rl� -Contractor
¢ y f J
a: rt w a OWNER-BUILDER DECLARATION BUILDING PERMIT .
o a o MISC.- REFER TO ORD - INFORMATIONil
X g n r I hereby affirm that I am exempt from the Contractor's License
FNo J Law for the following mason.(Sec,703 1.5,Businessand Professions PERMIT ISSUANCE VALUATION $/FT:
Code.Any city or county which requires a permit to construct,alter, 10.00
> ELEC.CONTR. LIC.N0.
¢ a ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.
o u requires the applicant for such permit to file a signed statement Lthaticense
TOTAL �l PERMIT TO
a w$w he is licensed pursuant to the provisions of 700 Contractor's License "/--A 4-
>0 Fi> Law(Chapler 9(commencingwilh Section 7000)of Division3 of the
i c Business and Professions Code)or that tie is exempt therefrom and OTY. PLUMBING PERMIT FEE
m r$ the basis for the alleged exemption.Any violation of Seclion7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant In a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(5500)):
❑ I,as owner of the property,or my employees with wages its BACK FLOW PROTECTDEVICE 400
their sole compensation,will do the work,and the structure is not . .
OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions - DRAINS-FLOOfl,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 5.00 166 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such Improve-
mentsarenotintendcdorofferedforsale.I f,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.000
or improvement is sold within one year of completion,the covert,
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 ofsule.). - INDUSTRIAL WASTE INTER3000 RES IND CON PB Omer
❑ I,as owner of the property,am exclusively contracting with . .
El ❑ ❑ 11licensed contractors to construct the project(Sec. 7044,Business LAWN SPR IN KLEflS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
El
and Professions Code:The Contractor's License haw docs 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 contraclods)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,RAP.C.I'or this
reason WATER HEATER III NY' ' 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREAT(NGFEQUIP.J 1, ') 5.00
I hereby affirm that I have a certificate of consent to scit-insure, ZONING ENG.SITE NO.
or acertificate o'Workers'Compensation Insurance,or a certified
copy thereof IS a,00„Lab,C)' V 6f Cupertino
Policy No. Co puny-
0 ❑ Certified cop t :byf sh FIRE SPRINK ENERGYT24
Z Z CertiDed y i fi1C II IC city inspection division. Y ❑ N❑ Y ❑ IN
Z O App ic:mt' MISC.- REFER TO ORD.
� y CERTI F FIiXEMF1 FROM WORKERS' PERMIT ISSUANCE VD FLOOD ZONE A.L.U.C.
LU OMPF-NSATION SURANCE. PLG.CONTR. LIC.NO. PLG.
CIL o (This section need not he completed if the permit is for one TOTAL a Y❑ N❑ Y❑ N❑
Z hundred dollars(5100)or less)
U O 1 certify that in the performance of the work for which this per- DTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL F- mil is issued,1 shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
y Date Apphcam ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTIC17 TO APPLICANT: If,after making this Certificate of Ex-
Z emption,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with U FEE such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10, 00CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10DWC.F.M.) 6.00 SEISMICFEE
1 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). HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that I have read this application and Hate that The above 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 reinsp
rty for
presentatives of
this ucity
'to. Curer cty to enter upon Th
above-mentionedproe BOILER-COMP 100,000 BTU)SEE FEESCH. MECHANICAL
pe
(We) agree 've, inde a keep hurnless the City of MISC.-' REFER TO ORD.
Cupertino Inst li biliti ,in g Is, costs and expenses which CONST.TAX
may i ny way cr ags aid City in consequence of the PERMIT ISSUANCE 10.00
gran of till m' MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signa Applicant/Contra Date - 71.
.OFFICE COPY