8380 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -`USE BALL POINT PEN ONLY
BU LOI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
C2 BUILDING-ELECTRICAL-PLUMBING -MECHANICAL P380
OwrvEH'S PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
TR M A PHDNE -
CONTRACTOR'S
rvAMe�•+� _ OUTLETS-SWITCHES-RECEP 10.00/1.00
. t-1- Mi- S LIC.NO. Z LIGHTING FIXTURES 10.00/1.00
ADDRESS TORS 410 5Q✓1 /.L(VZ`Q/�,\I� R17 • APPLIANCES-RESIDENTIAL 4.00
"f
PHONE - PANELS 10.00 DATE OF APPLICATION t'
ARCHIi ECPLAN CHECK FEE P.C.NO.:
OR PANELS (OVER 200 AMP) 20.00
ENGINEER A7DGus r- 'b3�4C�G`,MgrV/v )
uD.NO. SIGNS TRANS. 3.00 '
ADDRESS eea SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 PAID
ASMOTORS SEE FEE SCH.
ADDRESS
ADDR / ted
SERVICE CHANGE 20.00 WAN 2 �1 1U83
D¢ �_ TEMP.POLE 30.00
Foo LICENSED CONTRACTORS DECLARA'f10N city
fr1'rfp�{�pp
X v 1, 1 hereby affirm that I am licensed under provisions of Chapter 9 .a oISS'OMgC2Y Rk
w w (commencing with Section 7000)of Division 3 of the Business and
a vdi BLD ELE T. P G. MECH.
r• y z Professions Code,and my license is in full force and effect
Z o m - License lase-a J9 Lic.NUmhcr
9 m r Date Contractor '
a x E - � - BUIL I G PERMIT
¢O n ORGY Ii R-BUILDER DECLARATION POQI.S IN RMATION
X ; y 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u0a Law.(or the following reason.(Sca 7031.5,Busineisnnd ProfessimuAWATION $/FT.
H - PERMIT ISSUANCE 1990 G rrZ
Code:Any city or county which requires apermit to construct quer V V V
ec ¢4 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
U,
w m¢ requires the applicant for such permit to file a signed statement that TOTAL 'P2, O PERMIT TO
he is licensed pursuant to lite provisions of the Contractors License
Uzi Law(Chaptcr 9(commencing with Section 7000)nf Division 3 oflheaf `- �'•
F i o Business and Professions Code)or that he is exempt therefrom and
¢ m the basis for the alleged exemption.Any violation of DTV. PLUMBING PERMIT FEE
Section]031.5 STORIES TYPE CONSTR.
Ate _ by any applicant for a permit subjects the applicant to u civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more titan five hundred dollars($500).):
O 1,as owner of the$roperp',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,AR EA,COND. 5.00
Code:T'lie Contractors 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 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.Provided that such improve-
.ams are 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 he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose ofsale,). INDUSTRIAL WASTE INTER. 30.00 R5 IND CON PB Coe,
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 If 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(or such projects with a ammoteto(s)licensed pursuant to SEWER-SANITARY-STORM EA.2001t 1
the Contractor's License Law. / 0.00 TRACT NO. PARCEL NO.
❑ I and exempt Under Sec.-,BAP.C.for this _ WATER HEATER W/VENT 6.00
reason
Ownef Date WATER SYSTEM 5.00 ACG DATE ACC.FILE NO.
W'ORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to scl4insure,
or a certificate of Workers'Compensation Insurance,or a certified C9vV 4� //%• ZONING ENG.SITE NO.
Copy thereof(Sec.3800,Lab.C.). -
Policy No� Company-C
Q ❑ Ccrtl i'dcopy is lterchy f mKC ' FIRE SPRINK ENERGY T-14
Z Z ga. Certified copy is filed with the city inspection division.
O Ap lcent MISC.- REFER TO ORD. V[:] N❑ Y CD NE].
LUN v' MPT ON PERMIT ISSUANCE 7 p r r
7 CERTIF'ICAtT�I\''.PINSATON INSURANCEROM PLG.CONTR. LIC.NO. PLG. - 0. FLOOD ZONE A.LU L.
Z (This section need not be completed if the permit is 10, one TOTAL Y❑ N❑ Y ❑ N❑
hundred dollars($100)or less.)
U O I cattily that in Om performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued, 1 shall not employ any person in any Ammar I,as to
become subject to the Workers'Compensation lows of California.
Uw
Date-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING ?��d
>- 0 NOTICE TO APPLICANT: If.after making this Certificate of Ex-
F. Z mnptlon,you should become subject to the Workers'Compensmion APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, YOU most forthwith eon;ply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C:EM.) 6.00 SEISMIC FEE �J
I hereby affirm that there is a Construction landing agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,C,iv.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lenders Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC Jets
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and coumy PLUMBING CJU
ordinances and state laws relating to building construction, and BOILER-COMPO H.P.or 100,000 B.T.U:) 6.00 .7
hereby actioned representatives] fives of this city to enter upon the BOILER-COMP (Over 100,000 BTU(SEE FEE SCH. MECHANICAL Gs�
ubovrmenfioned Property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
• granting of this pertnit' MECH.CONT. LIC.NO. MECH.
a - TOTAL TOTAL
'
Sil5irtrc of Applictiontractor
INSPECTOR COPY