18463 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
IsUNING APPLICATION & PERMIT 8 4
ADDRESS 0
-_ -_ Z E21A! b.IR}' BUILDING - ELECTRICAL-PLUMBING-MECHANICAL S:
OWNER'S HyLIE SNU�TZ
PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
PHONE
CONTRACTORS
rvaME, OUTLETS-SWITCHES-RECEP 10.00/1.00
E 14 lent r4 4 LIC.NO 3o4471- LIGHTING FIXTURES 10.00/1.00
ADDRESSTO/RIS� PPLIANCES-RESIDENTIAL 4.00
-770 V(�T s. i PHONE X17 � ZZ PANELS 10.00 DATE OF APPLICATION "
ARCHITECT TECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO..
OR
ENGINEER
uD.NO. SIGNS TRANS. 3.00
ADOREss ENG' SPECIALCIRCUIT 5.00 PERMIT VALIDATION
�//,�
ZIP TEMP.METER OR POLE INS. 20.00
AMOTORS SEE FEE SCH.
ADDDRESSDRESS p
SERVICE CHANGE 20.00 /A
woo LICENSED CONTRACTORS DECLARATION
IF in U I hereby affirm that 1 am licensed under provisions of Chapter 9
y a w `AQd(commencing with Section 7000)of Division 3 of the Business and ISSUANCE DATE
H D Z Professions Codyyy,,and y icense is in full fo f and effect. BLDG. ELECT. PLG. MECH
o f o License Class l Lie Numberw 7'2.- ❑ E]
Date X r ContmctorAUQ T"9&9
-
a YBUILDING PERMIT
� w a OWNER-BUILDER DECLARATION
o' D MISC.- O OR INFORMATION
X g LL i- 1 hereby affirm that I am exempt from the Contractor's License
HuoA Law for the following reason, 7031.5,Businessand Professions PERMIT ISSUANCEVALUATION 8/FT.
Code:Any city or county which requires a permit to construct,alter, 10.00
SE 2 ¢ 0 improve,deanolish,or repair any structure.Prior to its issuance,also ELEC.CONTR. LIG,NO. ELEC.
o u requires the applicant for such permit to file a signed statnmm�f that TOTAL
n w m he is licensed pursuant to the withS Section
of the )Contractor's n License PERMIT TO
z a Law(Chapter 9(cosions Code)withorSection isexempDi Ent n l the CCG' (Lj.
i D Business and I'rofossions Code)or that he is exempt Ihcrcl'rnn and QTY. PLUMBING PERMIT FEE
Ic r w the basis for the alleged exemption.Any violation of Section 7031.5 1 STORIES TYPE CONSTR.
u _ by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollar,(S50O.): 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 OCC.GROUP RES.UNITS
intended
sole compensation,will(S the work,Business
the structure is not
-- Code:The
offered for sale(Sec. 7004, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply b an owner of
property who builds or improves thcrcon,provided
who tdoes
such
such work FIXTURES-PERT AP 5.OQ 50.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employeese provided that such such
ove-
mentsarenotintendedoroffered for sale.if,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or inh- . BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 E IND ON PB Ounr
❑ d as owner of the properly,he exclusively contracting with1:1
licensed croons Codtoconstructthe project(Sec. 7044,Business LAWN SPRINKLERS-1 INC5 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 thcrcon,and who LAWN SPRINKLERS-OVER 5(EAJ 1.00
contraufs fill such pbjens with a contmetons)licensed pursuant to
the Con rder License law. SEWER-SANITARY-STORM EA.200tt/10.00 TRACT NO. PARCEL NO.
O l uln exempt baler See ,It,SP.C.I'or Ibis
r ailWATER HEATER W/VENT 6.00
Owner Dan' WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconsent to self-insure.
or a certificale of Workers'Compensation Insurance,or a certifiM ZONING ENG.SITE NO.
copy ttereof(Sec.3800.Lab.C.).
Policy No. Company
O Certified copy is hereby fate vd RE SPRINK ENERGY T-24
Z 2 1�' Certijyd Lopy, Is le '1(the u s anon Division.
F O AnnliCanK/10-i{L, - MISC.- REFER TO ORD. Y N Y � N�
CC CIiRTIPI ATl:OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU � COMPIiNSAT10N INSURANCEPLG.CONTR. LIC.No. PLG.
CL O ('Phis wetion need not be completed if the permit is for one TOTAL Y[D N Y ❑ N
::) 2 hundred dollar,($100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any Inanner so as to
O W hewn e subject to the Workers'Compensation Laws of Cahlomin.
Q. Dam Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} 0 NOTICE "EO APPLICAN'1: If,after making this CEHjIc IC of[is-
f- Z cmption,you should become subject to file 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 10,OODC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a emotmetion lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work far which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 9.00 r
Lender's Name
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that 1 have read this application and state 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 representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH.
above-mentioned property for inspection purposes. MECHANICAL 3�Q�
(we) agree to save, indemnify and keep hornless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expmWes which 2 CONST.TAX
may in any way emu 'est said ity in consequence of the PERMIT ISSUANCE
•runfng of[his nit. MECH.CONT. LIC.NO. MECH.
TOTAL ^,�n�1
S' no co untractor Uutc ,C./�/ TOTAL -3,00
OFFICE COPY