7258 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADOREss .,C�qZC 8
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 7Ju
OwNER'a !/ PLAN CHECK VALIDATION
NA E J� QTY. ELECTRIC PERMIT FEE
U PRONE V
coNrnacroes OUTLETS-SWITCHES
-RECEP 5.00/1.00
NAME
S- vAp 1 - LIc,No, LIGHTING FIXTURES 5.00/1.00
CONTRACTORS _APPLIANCES-RESIDENTIAL 4.00
ADDRESS Z �' 1 A�1 �p -�/ �(/
Al J�CTL,QG'.NE /Z)..rO PANELS 5.00 DATE OF APPLICATION
ARCHITECT` SIGNS .6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADL!J 'UJT SPECIALCIRCUIT 5.00
. z CiFEfL
OaEss EMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS �1
J • Zp11t(.)ILc(t 2� Sa5 SERVICE CHANGE 10.00 .3/ •�/rf s/
wo o LICENSED CONTRACTORS DECLARATION �•
a u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
in a N (commencing with Section 7000)of Division 3 of the BBSi.B,,and BLDG. ELECT. PLG. MECH.
H N z Professions Coyk,Jy cy I yn II fore fie 1. e
z o m - License Cluxs g4,.afl��f I be,�,.i ❑ ❑ ❑ ❑
0 H w Date fly.W�-Contractor�.� -
a r� / 4C o•� - BUILDING PERMIT
Ix ,BE 4 OWNER-RUILDER DECLARATION INFORMATION
R
0 a y 1 hereby affirm Litt I am exempt from the Contractor's License MISC.- REFER TO ORD
.. o a Law for the f ldlowmg Rusin.(Sec.7031.5.Business and Professions PERMIT ISSUANCE _ VALUATION S/FT.
� - Code:Any city orcounty whichrequiresapenmit to construct,alter, 6.00
2 ¢ Q 2O improve,denlolisll,or repair any structure,prior to its issuance,alp ELEC.CONTE. LIC.NO. ELEC �/
as
0 ¢ requires the applicant for such permit 10 file ailment statement that TOTAL PERMIT TO
n w m LL he is licensed pursuant In the provisions of the Contractor's License [s
Uzi Law(Chapter 9(commercing with Section 7000)nf Division 3of tire tJ
e o .Q-{L.��J .J•
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i_: any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN -WATER (EA.) 4.00 -
of not more thin five hundred dollars(5500).1:
D I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCG GROUP RES.UNITS
their sole compensation,will do the work,art the structure knot
intended or offered for sal, (Sec. 7044, lousiness and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Cod,:'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 4.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such improve.
merits are not intended or offered for sale.If,however.the building GAS-EA.SVSTEM-11NC.40UTLETS q.00
or improvement is sold within one year of completion,the own". GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im RES IND CON PR Omer
prove for purpose of Sala). INDUSTRIAL WASTE INTER. 20.00 El El El❑ 1,as owner of the property,ant exclusively contracting with El El
licensed contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
andI'ro fcssions Code:The Contractor's Lie..Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA. 200ft/8.00 TRACT NO. PARCEL NO.
❑ I ant exempt under See. ,B.&P.C.for this WATER HEATER W/VENT 4.00
in
owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate ofconsem to eelf-insurs,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy there o'I S• 8 I.A.C.). /�
Policy No, tpauy C75 Cr�14-1363 CPA
O ❑ Ce i t it copy l I by fumisI it RE BPRINK ENERGY T 24
Certified coy�is Til- wfli Dm yb nS lion division.
H p Applicant // wu�t�-(�'// MISE.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
CCN CE.R1'It r"E01:EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LL > COMPENBATION INSURANCE PLG.CONTE. LIC.NO. PLG. / [
d Y N❑ v❑ IN EJ
O (This section need not be completed if the permit is for one TOTAL T
::) Z It undred dol l a,IS 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 F mit is issued.I shall not employ any person in any manner so as to
U
Obecome subject to the Workers'Compensation Laws of California.
w p�s-v
u Dale Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} in NOTICE TO APPLICANT: If,after making this Certificate of Ex-
♦- ? emption,you should Recount,subject to the Workins Compensation APPLIANCE 4.00 PLAN CHECK
provisions of fine Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,00DC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MCF.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT ITO 100,000 B.T.U.) 4.00
Lender's Name
HEATING UNIT(OVER 100,000 B.T.U.17.50
Lenders AddrAldo ess ELECTRIC.
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 -
information is correct. I agree to comply will,all city and county PLUMBING C/
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon tine BOILER-COMP(Over IGGLOOOBTU)SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree to ,ve, rode...nify and keep hornless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
granting this permit MECH.CONT. I.E.NO. MECH.
5 TOTAL TOTAL �S
ign ere of AppliczaktContmet.r f Dae
INSPECTOR COPY
t