2800 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI. POINT PEN ONLY
BU I LDING PROJECT I DENTIF I CATION PEIT R
BUILDING qa APPLICATION & PERMIT 4R
ADDRESS ,,// �\ O
/vi (,Uo[ lera, BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
00
OWNER'S PLAN CHECK VALIDATION
NAME I QTY. ELECTRIC PERMIT FEE
W11.lLAMS SONOIIA PHONE
corvTRACTORS UTLETS-SWITCHES-RECEP 5.00/1.00
NAME /an
k 4J4-ZCDA$'� J�V(vac.NO / s� LIGHTING FIXTURES 5.00/1.00
CONTRACTORS -RESIDENTIAL 4.00
ADDRESS
93J•}.S GbEZ>.S% PHONE V2!23237 PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 600 PLAN CHECK FEE P.C.NO,
OR
ENGINEER
uc.No SIGNS TRANS. 3.0
ARCH.OR ENG, SPECIAL CIRCUIT S,QD PERMIT VALIDATION
ADDRESS
zip TEMP. METER OR POLE INS. 15 0
APPLICANTS MOTORS SEE FEE S ,S
ADDRESS
SERVICE CHANGE 10.0
o 0 LICENSED CONTRACTORS DECLARATION
TP a I hereby affirm that I am OCenaed under provision,of Chapter 9 ISSUANCE DATE
HG d (commencing with Section 7000)of Division 3 f the&wines,and r In BLDG. ELECT. PLG, MECH.
F w z Profrszions Code,and license is in full foryy jy! fTi fro
Li cense Class C'4 Lie..Number :C 7-J ❑ ❑
9 R
Dole)_I_r) 99*4_Contrador CAL G(GAS`
a y f JI • e SJL:VLa
w -c OWNER-BUILDIiR IN BUILDING PERMIT
o " MISC.- REFER TO ORD
I F R f N
w3 a , I hereby aflinn that I ani exempt from the Contractor,License
LL o j Law for the following reason.(Sec 7031.5.Business and Profession, PERMIT ISSUANCE A uATION $/FT.
_ 6.00
Cade Any city or county which struirese permit toconsuanc Wteq
G improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEG. ItU ertin
O ¢ requires the applicant for such permit Io file a signed Matmnent Llon TOTAL PERMIT TO
n w m u he is licensed pursuant to the provisions of the Contractor's License
rzi
Law(Chapter 9(commencing w ith Section 7000)of Division 3 of the
- a Business and Professions Code)or that he is exempt therefrom and ()TY. PLUMBING PERMIT FEE
f p the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil Penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
OInot more than five hundred doll...(5500).1:
❑ I,as owner of the property,or my employers with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC,GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or Offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 4.00
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 4.00 SO.FT FLOOR AREA TOTAL ACREAGE
himself or through his own unployees,provided!Ilett such inipmyc-
rents are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 4.00
or improvement is sold within one yc.r ofcompletion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden Of proving that be dig not build or im" RES IND CON PB Omer
prove for purpose cfsalef. INDUSTRIAL WASTE INTER. 20.00 El El El E) El
I,as owner Of the property,am exclusively contracting with -
liemsed contractors to construct the project(Sec. 7044.Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
.nd Professions Code:'I'lie Contractor's License Law does not apply
10 an Owner of property whit builds or improves thereon,and who LAWN SPR INKLERS-OVER 5 (EA.) 1.00
contracts for such project,with a contractor(,)licensed pu..uant in
the Contractor's License Law. - SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO PARCEL No.
❑ tato exempt tinder Sec. .B.&,P.C.fur this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACCDATE ACC.FILE NO.
WORK ERS'COMPENSn1'[ON DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insum, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy th creat(Sec.3800.14.r v
Policy ert C0hnpany_
Q ❑ Certified copy i,hereby furnished- FIRE SPRINK ENERGY T 24
Z_ Z -�' CertiO con fled 'th file cit ins recti n clivi.' t. MISC.- REFER TO ORD.
Apalicantcc Us V ❑ N❑ V 1:1 NEI1- 'CIRTI PICA'f Ii OF:li lMl"pIOM1'ERON WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
UJ > COMPINSAT'ION INSURANCE PLG.CONTR. - LIC.NO. PLGv❑ N❑ Y ❑ N❑
(L O (This section need not be completed if the permit I% fur One TOTAL
D 2 hundred dioll.rs IS 100)or ESIJ
U O 1 certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued, 1 shall not employ any person in any manner so as to
Ow beconm subject to the Workers'Compenmtion Laws of California. BUILDING
Dine Applicant ALTER OR ADD TO MECH. 4.00 7
} tail NOTICE TO APPLICANT. If,offer making this Certificate of Ex-
F_ emotion,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provi,ions of the Labor Code, you must forthwith comply with FEE
U meth provisions or this permit shall he deemed revoked AIR HANDLING UNIT(TO 10SW C.F.M.) 3.00
CONSTRUC'nON LENIDING AGENCY AIR HANDLING UNIT(OVER 10=1C.F.M.) 5.00 SEISMIC FEE
I hereby afllrm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATI NG UNIT(OV ER 100,000 B.T.U.17.50 ELECTRIC 9 OQ
Lender's Address
I certify that l have read this applic.tion and date that the above VENTILATION FAN (SINGLE) 3.00
• informWion is correct. I agree Io comply with all City and County BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building con.vmmliois, and
hereby authorize representatives of this city to cnmr upon the BOILER-COMP (Over 100,000 BTU)SEE 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 end expenses which CONST.TAX
may in any way accrue against said City in conscq uence of the PERMIT ISSUANCE 3.00
gra f 11 nil[. MECH.CONT, LIC.NO. MECH.
OTAL
* / - y TOTAL �7 0O
Signature of Applicant ontmc[or Date
" OFFICE COPY