8911 (2) APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
^,AiSUI LD1 NG PROJECT I DENTI FI ON PERMIT NUMBER
BUILDINGA.
1 eT APPLICATION & P�JIIT
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 8911
1
tgf6.%LNO �',
OW ER' �Q �J .PLAN CHECK VALIDATION
NAME - 7/� -.J77 CITY, ELECTRIC PERMIT FEE
•� I�IE/A
LONTR TOR.a - -
NAME S UTLETS-SWITCHES-RECEP 10.00/1.00
4.1,X B 1201) 1J LIC.No S Z 3 LIGHTING FIXTURES 10.00/1.0
7� neo essi,Rs ZAPPLIANCES-RESIDENTIAL'
1'8S rw, C1 ,PHONE 3 Z PANELS 10.00 DATE OF APPLICATION
RCwieci PANELS 200 AMP) 20.00 PLAN CHECK FEE P.C.No
O .
OR
ENGINEERM
£c- UC.NOQ3P 1.2 SIGNS TRANS. 3.00 t
ARCH
ADDRESS ENG. SPECIAL CIRCUIT 5,00 PE _ ATION
A .-�83 ZIP EMP. METER OR POLE INS. 20.00 ��nI'nv n O 1�a6
Ars
ADDDRESSDRESS MOTORS SEE FEE SCH. Vr 1 Tj 1
•
SERVICE CHANGE 20.00 BSA
oa =. ( {{s�� atCuD.
r o O LICENSED CONTRACTORS DIiChA RATION TEMP.POLE 30.00
FZ W I hereby affirm Ilial I am licensed under provisions of Chapter 9 ISSUANCE DATE
w ¢ u (commencing with Section 7000)of Division 3 of the Betriess and
R EL PL ME
Professions Codq:ind my license is in full force nd ft$ gc).�
Z i._ License Class Q-__.Lit.Number,}�
o m r J Date#:= g.(;.._Cnntractor
¢ Ix w < / OWNER-ISUILDER DECLARATION BUILDING ERMI
x ; r I hereby affirm that I xm exempt from the Comrxcmr's License MISC.- REFER TO ORD INFORMAT
i0 .. o j Law for the following reason.(Sec.7031.5,Businesvmd Professions �� VALUATION $/FT.
r - PERMIT ISSUANCE 10.00 /
w i
Code:Any shy er sou my whiny requires epermit toconstruct,
uance,also ELEC.CONTR. LIC.NO.
¢ ¢ ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC. OD
0 u requires the applicant for such permit to file a si6ned statement that TOTAL
d x I 711
he Is licensed pursuant to the provisions of the Contractor's License PERM_ MIT TO /
r z t Law(Chapter9(commencingwith Section7000)of Division3ofthe
s 4 o Business and Professions Code)or that he isexempl therefrom and QTV. PLUMBING PERMIT FEE
¢ H the for the alleged exemption.Any violation of Section 7031.5 STORIESTYPE Cq TR.
by anyny applicant for a permit subjects Iheapplicant Ina civil penalty
ALTER
-DRAIN more than five hundred dollars($500)J: -DRAIN& VENT-WATER (EA.) 5,00
❑ I,as owner of the property,or my ernployees wi .th wa6es as BACK FLOW PROTECTDEVICE 4.00
their sole compensation,will do the work,and the struedue is not OCC.GROUP RES.yINITS
intended or offered for sale(See. 7044, Business and Professmus DRAINS-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 5.09 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such Squeve
ments are not intended or offered for sale.If,however,the hoilding GAS-EA.SYSTEM-11NC.4OUTLETS 6,00 L.
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
. prove for purpose of sale.). - INDUSTRIAL WASTE INTER. 30.00 IN./ IND CON PB Other
C11,as owner of the properly,am exclusively contmctilig with D ❑ ❑ ,❑
licensed contractors to construct the project(See. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply 1)
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) . 1.00 I
contracts for such proiects will,a cnntractorls111censcd,pursuanl to
the Contrctor's License Law" SEWER-SANITARY-STORM EA.200ft/10.00
��� ,,,NO. PARCEL NO.
❑ lam exempt under Sec. - ,B.&P.C.for this /
reason WATER HEATER W/VENT 6.00 /J
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORK 1:RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that d have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Laurance,or a certified ZONING ENG.SITE NO.
copy thereof(Set.3600, tib.C_ ,). _ _ -
Policy NoQ$$. 3c�t 8_>(e./ q�two n `
O ❑ Certifed copy rs h ruby fu rished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified tw thud will) the city Inspection division. Y N v N�
TAPPOb
./-tpW_� MISC.'- REFER TO ORD.
~'N PERMIT ISSUANCE 10.00
LU - CIiRTI PICATE F EXEMPTION PROM WORKERS'. FLOOD ZONE A.I.U.C.
W' COMI'IiNSATION INSURANCE PLG.CONTR. - LIC.NO. PLG. _
Z (This section need nut be completed if the permit is for one' TOTAL '� Y[:] N� Y [:] NE]
hundred dollars(SI00)or less.)
U O I certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL'1- snit is issued, I shot not employ an y'persnn in any manner pro In to
U w become subject Io the Workers'Compensation Laws of Calihuria. hh
y Date Applicant BUILDING
>_ W NOTICE TO APPLICAN'C If,after making this Certificate of E.- ALTER OR ADD TO MECH. 5.00
Z emption,you should become subject to the Workers'Contpensation qpp LIANCE 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 10DMC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE I
1 hereby affirm that them is a construction lending agency for ' EXHAUST HOOD (WITH DUCT) 5.00
Bill performane" 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- HEATING UNIT 100,000 B.T.U.)9.50
Lender's Address - ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4,00
information is correct.-] agree to comply with all city and county PLUMBING
ordinances and slate laws.relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
above- authorize representatives ins ec this city to enter upon the BOILER-COMP (Over 100,000 BTW SEE FEESCH. MECHANICAL
hereby authorize
property for inspection this
purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. �`�_•r
Cupertino against liabilities,judgments, costs and expenses whichCONST.TAX ^✓V
may in any way accrue against Said City in consequence of the PERMIT ISSUANCE 10.00
granting of this pennil / MECH.CONT. 'LIC.NO. MECH.
La�,.ai i3v 4 0,_r� y/+/) 86 TOTAL Ov TOTAL
Ignagre of Applican l/Contras or all
.. OFFICE COPY