C 8152 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
r�rBUILDING PROJE ENTIFICATION PERMITNUMBER
EnW,LDING APPLIC N & PERMIT
ADDRESS
G4 /� G? LD-1-4-7BUILDING—ELECTRICAL—PLUMBING—MECHANICAL , 152
o NER s
NAME
PLANC KVALIDATION
M P 4�—IRl CITY. ELECTRIC PERMIT FEE
CONTRACTORS
NAME
NAmE H7 OUTLETS-SWITCHES-RECEP 10.00!1.00 j —
t--,Vr uc.rvsLj]OJ / PO LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
S. = eyHONE I PANELS 10.00 DATE OF APPLICATION
ARRCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
O
ENGINES Sgq�` -
p7 + NSCk6IC.NO. SIGNS TRANS. 3.00 J'
AODRESs Ervc. SPECIALCIRCUIT 5,00 �` PERMIT VALIDATION
eA� OQ 0- a`Ib C 1 EMP.METER OR POLE I S s �Sr {
APPLICANTS MOTORS rSEE FEE SCH.
ADDRESS
RE SERVICE CHANGE 420.00 5
00 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a Z'w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE R
w a (commencing w Section 7000)of Division 3 of the Business and Gugerfino
BL ELECT,.
r D i Professions Co d my license is in full f,`
2 i c Licen I ss Lic.NumbeMtftl Bk
y r w D4Ic sContractor-_
F F J �
o i OWNER-BUILDER DECLARATION BIIN ATION
W ; u I hereby affirm that 1 am exempt from the Contractor's License MISC.— REFER TO ORD VALUATION F w
U.
J Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 1990 -r S/FT.
fw0 Code:Anycity arcounty which requires a permit to construct,alter,
rc ¢ ¢o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONED. LIC.N0. ELEC.
y O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w m he is licensed pursuant to the provisions of the Contractor's License S
Law(Chapter 9(commencing with Section 7000)ofDivision3ofthe Si"It"-e7A7 ,., R"-f,
i o Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
H the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPF CONSTR.
n ; by any u
e
applicant lora permit subjects(be toucivil penally S�z
of not more applicant
lira hundred dollars(be ): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ I,as owner of the property,or my employees with wagesas BACK FLOW PROTECT.DEVICE 4.00 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. 5.00 /t—
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work 1 I F IXTUR ES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve. q p (^
ments are not intended or offered for Sale.If,however,the building I GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM OVER 4 IEA) 2.00
builder will have the burden of proving that he did not build or im - . BUILDING USE
RES IND CON PB Omer
E)prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑. ❑
ass owner
of the property, exclusively contracting with
licensedd contractors to construct the
project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law Joos not apply
to on owner of property whhbuilds
o builds or improves(hereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a conlmetons)licensed pursuant to
the Contractors License Law. I SEWER-SAN ITAR V-STORM EA.200ft/1 BLAB TRACT NO. PARCEL NO.
❑ 1 no exempt under Sec. ,B.&P.C.for this
reason I WATER HEATER W/V T E in I � � ���
Owner Date WATER SYSTEM - 5109
L Jls' ACC.GATE ACC.FILE NO.
WORK 17RS'COMPENSATION DMLARATION WATER TREATIN I ;; 5.00
I hereby affirm that I have a certificate of consent to self—insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy Pol cy Noeof(Sec.3gCOnspany_—US F'i'. //
O ❑ ified copy is hereby furnished. FIRE SPRINK ENERGYT24
Z Z Certified 1. y is _RIyQ with the city inspection division. MISC.- REFER TO ORD. ❑ ❑ ❑ F]Applicant V N V N
CC �+ PERMIT ISSUANCE •?700
LU — CF RTIPICCOMOF COMPENSATION
FROM WORKERS' FLOOD ZONE A.LD.C.
W COMPF:NSA7'ION INSURANCE PLG.CONTR. LIC.NO. PLG.
Z
This section need not be completed it [lie permit is for one TOTAL O V❑ N❑ Y❑ ry❑
hundred dollars($100)or less.)
U O 1 certify that in the performance of the work for which this per CITY MECHANICAL PERMIT FEE FEE SUMMARY
W F mil is issued,I shall not employ any person in any manner so as to
O w become subject to the Workers'Compersut ion Laws of California.
Q. Datc Applicant BUILDING 13-4pfN
>- m NO'TICF-TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
2 emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
Provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be decried revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IO,OODC .18.00 -SEISMIC FEE /01�
I hereby affirm that there is a construction lending agency for ( EXHAUST HOOD(WITH DU '1 's 5.00
the performance of thew k which t cant is issued(Sec. MICROFILM
3097,Civ.CJ. `� r 1 HEATING UNIT(T0100,000 B.T. 1
Lender's Name
HEATING UNIT .U'. 50
Lender's Address - 00 ELECTRIC �d3�
I certify that I hove read this application colonic that the above `3 VENTILATION FAN (SINGLE) 2—
s information is correct. I agree to comply with all city and county PLUMBING 70 p`+-
ordinances and state laws relating to building construction, and BOILER-OOMP(3 H.P,or 10 .00
hereby authorize representatives of this city to enter upon the
above�mbnlioned property for inspection purposes. BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL J
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. - Oti
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 Q CONST.TAX
may in any way accrue against said City in consequence of the
granting ofINS pl,rm MECH.CONT. LIC.NO, MECH.
UAV LO� 3/I 8 TOTAL �r w TOTAL
ignature cop Rcant/Contractor Date
OFFICE COPY