8139 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LOINS PROJECT I DENTI FI CATION PERMIT NUMBER
ADDRFG APPLICATION & PERMIT �� ��
no IL.M5
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S / PLAN CHECK VALIDATION
"^MEcHRKLES STEUEU ����E� QTY. ELECTRIC PERMIT FEE
ACT° s
o5c 7' _
NOME PHONE (90P
UTLETS-SWITCHES-RECEP 10'.00/1.00
1
ua No. JAILIGHTING FIXTURES 10:00/1.00
ADDRESST s APPLIANCES-RESIDENTIAL 4.0,
PHONE I PANELS 10.00
S DATE OF APPLICATION
A CHT CTV ICA" 0442 PLAN CHECK FEE P.C.NO.
OR ( PANELS (OVER 200 AMP) 20.00
ENGINEER
' SIGNS TRANS. 3.00
noo"R Ess SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ztv TEMP.METER OR POLE INS. 20.00
APPLICANT'S
AooREss MOTORS SEE FEE SCR.
SERVICE CHANGE 20.00 1
/Cj
woo LICENSEID CONTRACTORS DECLARATION TEMP.POLE 30.00 / JS�
c v I hereh,affirm that I am licensed under provisions of Chapter 9
Z iw ISSUANCE DATE¢ w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F N z Professions Code,and my license is in full force and effect
z o ®\
H - License Claxs Lie Numbeitr�(hyg�
� r w Date Contractor p:-�p//��.CCaa
a x BUILDING PERMIT
¢ 0 w a WNF:R-d DlhDfiR DECLARATION
Iso U INFORMATION
; a 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
r t. oa Law for the following reason,(See.7031.5.Busimessand Professions PERMIT ISSUANCE 1�.Q VALUATION "FT.
pyo Code:Any city or county which requires permit to construct,.ler,
ac ¢ ¢ o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. p
¢ requires the applicant for such permit to file a signed statement that d TOTAL p �'' an
n w m w he is licensed pursuant to the provisions of the Contractor's License r0
� z >
Law(Chapwr 9(commencing with Section 700()of Division 3 of the
5x 4o Business and Professions Code)or that he is exempt therefrom and QTY.
aPLUMBING PERMIT FEE
R F m the basis for the alleged exemption.Any'violation of Section 7031.5 ST gIES TYPE CONSTR.
by any applicant for a permit subjects the applicant ton civilpenally ALTER-DRAIN -WATER IEA.) $,00
of not more than five hundred dollars($500).):
❑ I,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 oce.GROUP RES.UNITS
intended or offered for sale(Sec. 7044; Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contredor's License Law does not apply to out owner of
property who builds or improves thereon,and who dock such work FIXTURES-PER TRAP 5.00 _
himself or through his own employees,-provided that such improve-
SQ FT.FLOOR AREA TOTAL ACREAGE,
mentsare not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00 .
or improvement is sold within one year of completion,the owner
builder will have the burden of proving that be did not build or im- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
prove l'or purpose of sale.) N INDUSTRIAL WASTE INTER. 30.00 RE IND CON PB Omer
O I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- i INC 5 V.B. 6.00 BSESSORS PARCEL NO.
and Professions Cade:The Cont rudor's License Law docs 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(sl licensed purse ant to
the Contractor's License law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL No.
• ❑ I am exempt under Sec.-,B.&P.C.for this WATER HEATER 6.00 '
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK 1:RYCOYIPENSATION DI-CLARATION WATER TREATING EQUIP. 5.00
1hereby affirm that 1 have a certificate of consent to self-insure.
or a certificate of Workers'Compensation Insurance,ar a certified ZONING ENG.SITE NO.
> copy thereof(Sec.3800,Lab.C.�-
Policy Nnl;fompany
Q ❑ Ce hie py4o hereby furnished. FIRE SPRINK ENERGY T 24
Z Z g Certiial copy is Filed
with the city inspection Division.
P O�/ AphlicanL 1/'"PE5 ,A6F '� MISC.- REFER TOORD. Y0 NE] Y [] NE .
OC N CERTIFICATE OF EXEMPT]ON FROM WORKERS' PERMIT ISSUANCE _=0 ( FLOOD 2orvE a.L.U.C.
W > COM111:1, AT10N INSURANCE PLG.CONTR. LIC.NO. PLG.
1 (This section need not be completed if the permit is for one TOTAL v N� Y E] AD
Z hundred dollars(S100)or less.)
U 0 1 certify that in the performance of the work I'or which this per- OTY s MECHANICAL PERMIT �^ FEE FEE SUMMARY
LL I- mit is issued, I shall not employ any person in any manner So as to
U become subject to the Workers'Comptucition laws of California. _
Q. Uarc Applicant ALTER OR ADD TO MECH. 500 �/ BUILDING Q
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex- 4 n
•� Z emption,you should become subjed to the Workers'Canpensalion APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall he deemed revoked, AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE // 3
1 hereby afl'inn 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,Civ C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the above If VENTILATION FAN (SINGLE) 4.00
inf�. and inmation n correct I agree to comply with all city and count), BOILER-COMP(3 H.P.or 100,000 B.T.U.) ,6.00 PLUMBING
diby au and state Taws relating to is cit ng comer non, and
hereby authorize representatives her inspection
of this rp' to enter upon the 801 LER-COMP 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes. �!)
(We) agree m save, indenmil'y and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 1CONST.TAX
may in an0.00 y way accrue against said City in consequence of the _
granting of this permit. MECH.CONT.s, LIC.NO. MECH.
ut C' I;- d �„�
-�+R�c�� y/9/RS
$hgaafto d}TAPPIFd n r'�`"A'''3 tt TOTAL �.^f TOTAL ✓ j
INSPECTOR COPY V el