8487 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
aG,L� R fvv GE oa APPLICATION & PERMIT
/was A °� dQ
4 46BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 847
0
° PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
ONE
C0 UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
r r- ;44 LIc.No. y LIGHTING FIXTURES 10.00/1.00
Acro
ADDRESS PPLIANCES-RESIDENTIAL 4.00
VR°NE PANELS 10.00 PATE OF APPLICATION
OR
A " EC PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIF.No. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION /
ZIP TEMP.METER OR POLE INS. 20.00
ADDRESS rs MOTORS SEE FEE 0.00
ADDRESS
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
G v I hereby affirm (hat I am licensed under provisions of Chapter 9 ISSUANCE DATE
w a w (colamawing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. Egli
y z Professions Cod,,and my license is in full force and effect
z o w - License Class Lic.NWrlber
9 a, D Dol, Contractor
a x s BUILDING PERMIT
¢ ¢ w a
OWNER-BUILDER UECLARA'1'ION INFORMATION
o e. ° MISC.- REFER TO ORD
w g. I hereby afl'inn Iho( I um exempt from the Contractor's License
. VALUATION SIFT.
FLLoI Low for the ityfollowing
oonly whichelaire.5.Businessandtro ,aloes PERMIT ISSUANCE 10.00
Code:Any city or I,or rep which requires a Permit to constant,also
¢ ¢ ¢ 0 improve,demolish,or repair any structure,prior to Els issuance,also ELEC.CONTE. LIC.NO. ELEC.
K m u requires the applicant for such permit to file a signed statement that v TOTAL PERMIT TO
.u w he is licensed Pursuant to the Provisions of the Contractor's License
r zt- Law(Chapter 9(commencing with Section 7000)of-Division 3 of(he
fa Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
r
¢ 1 0. the basis for(he alleged exemption.Any violation of Seaton 703 1.5 STORIES PE CONSTR.
d ,. by any applicant for a permit subjects Ore applicant to a civil penalty
.few mom than five hunAn:J Dollars(5500).): ALTER-DRAIN& VENT-WATER (EA.) 5.00
❑ 1,as owner of(he property,or my employees with wages as 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,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 FIXTURES-PER TRAP 5.00 5O.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees.Provided that such improve-
ments are not intended or offered for sale If,however.tire building GAS-EA.SYSTEM-1 INC.4 OUTLET$ 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 (EA) 200
builder will have the burden of proving that he did not build or inn- - . . .
- BUILDING USE
Prove for purpose ofcde.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct lire 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 o1'property who builds or improves(hereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to SEWER-SAN EA.200t[/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Scc. ,B.&P.C.for Ibis WATER HEATER W/VENT 6.00
reason
Owner [)ate WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00
I hemby affirm flat I hnvo u certifmate of comma(to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(See 3900,Let,CA
policy No. Company
0 C Certified copy is hereby furnished FIRE SPRINK ENERGY T 24
Z Z O Certified copy is fled wilh the city inspection division.
O Applicant MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
CCy Cl:R1'IFICA'117 OP FX EM le I ON F ROM WO R K E RS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.uc.
LL > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
CL Z (This section need not be completed if [:Jthe permit is for one TOTAL Y N❑ Y E] ❑
N
hundred dollms IS 100)or less)
U'O 1 certify (hal in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner w as to
become subject to the Workers Compensation Laws of California.
} n� Date / 'ca:n
BUILDING„ ncf ALTER OR ADD TO MECH. 5.00
IWNOTI i �CANIL 'It
,x-
F Z emption,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 1000C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT)
tine Ciorcance of the work for which this per is issued ISec HEATING UNIT(TO 100,000 B.T. .) 8.00 MICROFILM
Lender's Nam, HEATING UNIT(OV ER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
1 certify that I have real this application and state that the aboveJB
ENTILATION FAN (SINGLE) 4, A
• information is correct I agree m comply wiOl all city and countyOILER-COMP(3 H.P.Or 100000 B.T.U.) 6.00 / PLUMBING
ordinances and state laws relating to building construction, andhereby authorize representatives of this city m enter upon theOILER-COMPIOva,100,0008TU)SEE FEESCH. MECHANICALabove-mentioned property for inspection purpu-(We) agree to save, indemnify and keep Imrmle" the City ofISO.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 1 CONST.TAX
may in any way acerae against said City in consequence of the
gmnlin•of this pernit. MECH.CONT. LIC.N0. MECH.
TOTAL TOTAL �1`0
Si f E/C Dmc
INSPECTOR COPY