C 8151 APPLICANT TO FILj IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDINGPROJEC NTI FICATION PE IT NUMBER
BDI_LD IN4r- - APPLICAW & PERMIT
A° '*55/• '/ a� ,,� 8151
�i � VC'FVV E j` BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S f PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
r Pr4_VG NE -19
CONTRACTORS
NAME TJ fef JOUTLETS-SWITCHES-RECEP 10.00/1.00
Corp. LIC.No.thSlOI���n `L0 LIGHTING FIXTURES 10.00/1.00
noaaEss TORS
San 50S'P •.+�•�I PPLIANCES-RESIDENTIAL 4.00 ^�
SO. O I PANELS DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP),,' 20.00 PLAN CHECK FEE P.C.NO.
ENGINEE i,,,,,,,
LC.N.. SIGNS TRANS, 3.00
ARCH'Ess ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
nPgg10I0 1 EMP:METER OR POLE INS. 20.00
APPLICANT s p MOTORS SEE FEE SCH.
ADDRESS 11'1 -(3 S. SbLrarD9q /SmIe
qv) ,Toe tall SERVICE CHANGE 20.00 .•.a
0 0 2 0. -1 LICENSED CONTRACTORS DECLARATION TEMP.POLE 3 - _ O
<i w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
N (commencing with Section 7000)of Division 3 of the Business and
a n f
BLDG
(commencing ELECT. PLG. MECH.
0 a z. Professions Code, my license is in full finegslorlrt(e ❑ ❑ ❑
x O= License ss. se i Number .�766�J f�
0 m H w Date . ConUuclor.�b[fy1"
yatJ
E rc at st OWNER-BUILDER DECLARATION 0 BUILDING PERMIT
w3:A y 1 hereby affirm that I am exempt from lire Contractor's License MISC.- REFER TO ORD INFORM T ,
H u o J Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE V�A,LUATION 1. ]
w0 Code:Any Cilyorcounty which requires a permit to construct,alter, 11$68 jG! oOO
Q Q 4 0 Improve,demolish,Or repair any structure,prior to Its Issuance,also ELEC.CONTE. LIC.NO. ELEC. a
y e u requires the applicant for such permit to file a signed statement than TOTAL 3/ PERMIT O )RQ
m m he is licensed pursuant to the provisions of the Contrimlor's Licenm
r Z i
Law(Chapter 9(commencing with Section 7000)of Division 3 yfthe
4 Business and Professions Code)or that he is exempt IhereGom and OTY. PLUMBING PERMIT FEE e! r
r the basis for the alleged exemption.An violation of Serums 7031.5
8 p y STORIES TYPE C STR.
i ; _ by any applicant for a permit subjects the eoplicawa civil penalty
of not more than five hundred property.
fS5 mp ALTER-DRAIN& VENT-WATER (EA.) 5.00
O I,as owner at the p.ai,, .':or ,and t nes with wages as BACK FLOW PROTECT. DEVICE 4,00
their stile compensation,••gym.�,•rte work,and the structure is not OCC.GROUP RES.UNITS
intended or offered or sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND- 5.00 ,4,- ,3 /
Code:The C-,radon's License Law does not apply to an owner of
property,who builds or improves Orercon,and who does such work I,1 FIXTURES.PER TRAP '6d050.FT.FLOOR AREA TOTAL ACREAGE
himses or through his own employees,provided that such improve
-;_s are not intended or offered for sale.IL however the building GAS•EA.SVSTEM-11NC.4 OUTLETS 6,00 �.;f`rr
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 CON PB Omar
O I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(See. 7044,BusinessLAWN SPRINKLERS-1 INC 5 VB600 ASSESSORS PARCEL N0.
and Professions Code:The Contractor's License Law does not apply V.8. .
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 O
the Contractor's License Law, I SEWER-SANITARY-STORMEA.200ft/MM C TRACT NO. PARCEL NO.
O 1 am exempt under Sec. ,B.&P.C.for this
4eason I WATER HEATER W/VENT '7ai3
Owner Date ( WATER SYSTEM
A A9P4 ACC.GATE ACC.FILE NO.
WORK ERS'COMPENSAT'ION DECLARATION WATER TREATING EQUIP.- 5.00
I hereby affirm that I have a certiricate of consent to sel Gitimm,
of a certificate of Workers'Compensation Insurance,or a certified 'I�l].. ZONING ENG.SITE NO.
Policy No,-Company
(See.3g ) u5�'}
0 ❑ j]erlifled 'opy is hereby furouload. FRE SPRINK ENERGY T-]G
Z Z Certif• copy is filed with tire I
e city inspection division.
� 0 Applicant_ b(,Q�`_�`,Qrp MISC- R FERTO ORD. N[:] V N4
Lo CERTIFICATE:OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE JAAO FLOOD ZONE A.L.U.c.
W COMPENSATION INSURANCEPLG.CONTE. LIC.NO. PLG. .r ❑ ❑
1 O ❑ ❑
(This section need not be completed if,the permit is for one TOTAL V N V N
D Z hundred dollars IS 100)or less,)
0 O 1 certify that in the performance of the work for which this per- DTV MECHANICAL PERMIT FEE FEE SUMMARY
W F mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workeri Compensation Laws of California. _
i Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ to NOTICE. TO APPLICANT: If,after making this Certificate of Ex-
F. Z emplion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
C,.1 such provisions or this Permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 1(WC-F. .) 6.00 SEISMIC FEE
1 hereby affirm.that there is a construction lending agency for 1 EXHAUST HOOD(WITH DUCT) 5:00
the performance of the rw�ar for whi this permit is issued(Sec. + Imo,B.dO �, MICROFILM
Lende"3097. ...... (^QI•t HEATING UNIT(TO I
Lender's Name s 9e �K ELECTRIC
_ Lender's Andrei; - fY1ri ICP4-�;': ���a � HEATING UNIT(OV ER 100,000 B.T.U.)9.50 - I
- I certify that I have read this application unit state that the above VENTILATION FAN (SI$1 a UOer to
• 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 7O
hereby authorize representatives of this city to enter upon the MECHANICAL 3
above-mentioned property for inspection purposes. BOILER-COMP 10anr 100,000 BTU)SEE FEE SCH.
(We) agree to save, indemnify and keep harmless the City Of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00/0- CONST.TAX SLf
ranting Of this per 'IECH.CONT. LIC.NO. MECH.
3V1 TOTAL 35 Date TOTAL /OS�3�
Signature of App scant/Co tr.clot
OFFICE COPY