8153 (4) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
9UI LDI NG PROJE NTI FICATIONf PERMIT NUMBER
emLmNa APPLICA N & PERMIT'•
ADDRESS 1
�� �� G-- .. }� BUILDING — ELECTRICAL—PLUMBING—MECHAN AL 8153
NAME ER's PLAN CHECK VALIDATION
N
(0(JJf YYl .. DTV. ELECTRIC PERMIT FEE
E
CONTRACTORS
NAME B"( UTLETS-SWITCHES-RECEP 10.00/1.00
Y cov— Coro. LIC.NO, pl e20 ILIGHTING FIXTURES 10.00/1.00
DOR's
ADDRESS DRESS slaq PPLIANCES-RESIDENTIAL 4.00
A �• �Q`��, ,,11
11'7-3-19 p,V}{M SUD,IQBONE�t4(D—I 1 PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
on PANELS (OVER 200 AMP) 20.00
ENGINEER
SIML
+ c.No. SIGNS TRANS. pain 3.00
ARCH.08
ADDRESS ENG. SPECIAL CIRCUIT 5,00 PERMIIFrAINgON
G V k Iq P Rtib 1 TEMP.METER OR PO C 0
APPLICANT'S 1985
ADDRESS MOTORS SEE FEE SCH.
11l S, qTI SERVICE CHANGE 0
M o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 C1O AFhBU
< u w I hereby affirm that I am licensed under provisions of Chapter 9
Q A ISSUANCE DATE ,
(commenting wit d my l 700e it Division 3 of the Business and
r D i Professions Cod J my license is N'full for lrff¢Sh
SLOG. ELECT. PLG. MECH.
o i o License I Lie Numb �] I -
r Contractor IJP LT' LJ-'
rc Q w a OWNfiR-BUILDER DECLARATION BUILDING PERMIT
o A. D INFORMATION
X ; a I hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD
H LL o¢ Law for the following reason.(Sec.7031.5,Business and Professions VALUATION S/FT,
i PERMIT ISSUANCE -app �y�p BUQ
w Code:Any city or county which requires permit to construct,alter,
ea M e o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC.L
0¢ requires the applicant for such permit to file a signed statement that J
A w a- he is licensed pursuant to the provisions of the Contractor's License TOTAs,N PGL-GRRM T TA•._ `
H z < Law(Chapter 9(Commencing with Sect ion 7000)of Division 3a fine
4 D Business and Professiohis Cole)or that he is exempt therefrom anti DTV. PLUMBING PERMIT FEE
m H B the basis for the alleged exemption.Any violation of Section 7031.5
STORES TYPE CONSTR,
n ; •- by any applicant fora permitdollars $500).licant loacivil penalty S N�
of not more than five hundred dollars(he app: ALTER-DRAIN& VENT-WATER IEA.) 5.00
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Set. 7044, Business and Professions 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 If FIXTURES-PER TRAP 5.00 SD.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments am not intended or offered for sale+if,however,the building 1 GAS-EA.SYSTEM-I INC.4 OUTL p,00 LSI
or improvement is sold within one year of completion,the owner•builder will have the burden o'proving that he did norbuild or im- GAS-EA.SYSTEMOVER 4 A.1 2.00NG USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. ON PB Omer
❑ I,as owner of the property,am exclusively contracting with ❑ 1:1 11licensed contractors In construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 I V. 0 PARCEL NO.
nd Professions Code:The Contractor's License Low does not applyto an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA 1 1contracts for such projects with n contnctots)Ilcenwd pursuant to
the Contractor's License Law. SEWER-SANITARY•STOR 0 PARCEL NO.
❑ 1amexemptunderSec. ,B.&P.C.for this 1WATER HEATERW/VENT BAO reasonOwner Date ( WATER SYSTEM ACC.FILE N0.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconseat to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified [s ZONING ENG.SITE NO.
Policy No, (Sec.3BCompany ) 1.15 F J—�l `�
O ❑ ertifed copy is hereby furnished. EFIRESPRINKLENERGY2a
Z Z v c:rt conysGlad with the city Inspection division.O Applicant_-10GC✓' MISC.• REFER TO ORD. NE]
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. '•D• o fThis section need not he completed if the permit is far one TOTALN�
D Z hundred dollars(8100)ar Itis.)
U O I certily that in the performance of the work for which this per' DTV MECHANICAL PERMIT FEE FEE SUMMARY
F
LL mit is issued,1 shall ant employ any person in any manner so as to
Dbecome subject to the Workers'Compensation Laws of California.
y Date Applicant BUILDING
} m NOTICE 'f0 APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5,00 �x�3
I.. Z emption,you should become subject to the Workers'Compensation APPLIANCE {x5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
(� such provisions or Ibis permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000 F.M.) 4,00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER iMf=241 ,OO 0 SEISMIC FEE /0 • 6
I hereby affirm that there is a construction lending agency for I EXHAUST HOOD (WITH 5.00 .S"-
the performance of the wot�rrk'k1 for Ich this p tt is issued(Sec. 1 HEATING UNIT(TO 100,00 .T MICROFILM
Lend,is Nam . CaliT 1�5• I5ti Y1�.
Lender's Name
Lender's Address HEATING UNIT(OVER ER 100,. B.T.U.19.50
�5�. --- ELECTRIC 131 �
I certify that I have read this application and state that the above 3 VENTILATION FAN (SINGLE) 4.00 L
information is correct. I agree to comply with all city and County BOILER- H.P.or 100,000 B.T.U.) 6.00 PLUMBING 70 i
ordinances and state laws relating to building construction, and
hereby authorize representatives ec this city to enter upon theaboveBOILER-COMP IOver100,000BTU)SEE FEE SCH. MECHANICAL 3�`,'V
hereby
ned property tar vespof this
purposes.
(We) agree to save. indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which ,�� CONST.TAX
§I^.fth.s
in any way accrue against-said City in conuyuence of the PERMIT ISSUANCE 10.00 ✓J
p niL %C MECH.CONT. LIC.NO. TMECH
OTAL b
G-In= JTOTAL V,iP �ture at A li cat/Contractor Uate
OFFICE COPY