C8644 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
0UBUILDING PROJECT IDENTIFICATION PERMIT NUMBER
ILDE1N APPLICATION & PERMIT
� AooREss A
S gL�. V• BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 8644
OWNER'S Nom. PLAN CHECK VALIDATION
NAME ' OTY. ELECTRIC PERMIT FEE Q Ao
PHONE
CONTRACTORS
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
1r ('Ot)ZZ7V uC.NCT LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
], aooREss
YJ ONE PANELS 10.00
DATE OF APPLICATION
OR riECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER _
LIC.No. 4 SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS /� SPECIAL CIRCUIT -I 5.00 b A
ZIP', EMP:METER OR.POLE'INS. ,/ 20.00
APPLICANT DESS 's
AIR \ z MOTORS "1' • ` SEE PEE SCH.
SERVICE CHANGE 20.00
Foo LICENSED CONTTEMP.POLE 30.00RACTORS DECLARATION /0
a z w 1 hereby affirm That 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
maw (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
N z Professions Code,and my license is in full force and effect ❑ ❑ ❑ 112 O Sar License Class 9-/ iia Nu... ICG '
o r Date <-,6t Contmcto�A'I��
< x �f OM1""v BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DE`s' R
o a u INFORMATION
w LL Li¢nsc MISC.- REFER TO ORD
I 1 hereby affirm (farI am exempt from the Contractor's
F . oat Law for the following rWxcn.(Sec.7031.5.BD,iRci)and Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
Code:Anychy orcouity which requires a permit to construct,alter, ✓ � V
¢
> p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O u requires the applicant for such permit to file a signed statement that TOTAL
a w m m he is licensed pursuant to the provisions of the Cootmctoi s License PERMIT TO
>'
Law(Chapter 9(cohmnencing with Section 7000)of Division 3 ofthe
io Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
re r O the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
ea by any applicant for a perm it subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 6.00
of not more than five hundred dollars(S500)):
❑ I,as owner of the property,or myemployees with wages as BACK F LOW 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 IS, 7044, Desires and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:'fie Contractor's license Law does not apply to an owner of
property who builds or improves t ancon,and who docs such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such in.prove-
mmes are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is,mill within enc 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 int- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES IND CON PB Orbe,
❑ I,as owner of the property',am exclusively contracting with . .
❑ ❑ ❑ ❑ ❑
heem,ed 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 does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. I SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Scc. ,B.&P.C.tisr this WATER HEATER W/VENT 6.00 -'^*
reason '
Owner Date WATER SYSTEM 5.00 ACC.oarE ACG FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm list I have a certificate of Consent to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.I.
of Policy No.ayyriG;`�y)Chmp:my CO P•
O ❑ Ccriticdeop h. ilc[e urn edf FIRE SPRINK ENERGY T-24
z Z �(Y Cenif py 'wi h/th' ii mapedh hvI
Or A(SAlicantlcL� MISC.- REFER TO ORD. Y _ NE] Y ❑ NE]
N/ CIiRTIFICA'I'E 01'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C. .
LL > CO,M1IPET HON ON I NSU R ANC Ii PLG.CONTR. LIC.NO. PLG.
Z (This section need not be completed if (lie permit is for one TOTAL Y[:] NEJ Y[:J NC]
CJ O hundred dollars($100)or less.)
1 certify that in it,,.per(or...ance W the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued.I stuff not employ any person in any Claimer so as to
become subject to the Workcri Compensation Laws o(Califomia.
0 a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING 7
} W NOTICIi '1'0 APPLICANT'', If,after making this Certificate of Ex-
h 2 cmption,you should become subject to the 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=CF.M.) 4.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Cis C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name H EATI N G U N IT I OV ER 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 n correct I agree to comply with all city and county BOILER-COMPM H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances formatio and state laws relating to building construction, and
hereby authorize representatives of this city hh enter 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 liabilitie,judgments, costs and expenses which CONST.TAX
may is an wa ac guinst said City in consequence of the PERMIT ISSUANCE 10.00
gr MECH.CONT. LIG NO. MECH.
S e TO AL
TOTAL I`4-/ 3-
Y WurL� h rector Date
INSPECTOR COPY
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