8234 APPLICANT TO'FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATION
PERMIT NUMBER
BUILDING APPLICATION & PERMIT f
ADDRESS p,
/ BUILDING - ELECTRICAL-PLUMBING-MECHANICAL (�
OWNER PLAN CHECK VALIDATION
T NAME
QTV. ELECTRIC PERMIT FEE
PHDNE
t N NNT D Rs OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC,No, LIGHTING FIXTURES 10.00/1.00
ADD AcroR's PPLIANCES-RESIDENTIAL 4.00 '
ADDRESS ` WIP
PHONE PANELS 10.06 DATE OF APPLICATION
OR PANELS CT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
FC; a
LIC.NO. SIGNS TRANS. 3.00
ADDREOR
SS SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
n ZIP EMP.METER OR POLE INS. 20.00
ADDRESry s MOTORS SEE FEE SCH. /
AooREss
a SERVICE CHANGE 20.00 /U
a TEMP.POLE 30.00
Foo LICENSED CUN'I'RACI', RS DGCLA R.CPIA ✓iW
a u v 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANE DATE
m "'
(commencing with Section 7000)of Division 3 of the Business and
Q a g BLDG. ELECT. I PLG. MECH.
F i Professions Code,and my license is in full force and effect
i w o7,License Class $_Lic.Number
o �r
Date�$�-Contractor y L ,e¢
a Y
21 / / BUILDING PERMIT
¢o ec OWNER-BUILDER DECLARATION INFORMATION
E:
3 1 e, I hereby affirm flat I um exempt from the Cnutr:mtor's License MISC.- REFER TO ORD
u O g Law for the following reason.(Sec.7031.5,Businessand Pooficiamm, PERMIT ISSUANCE 10.00 VALUATION $/FT.
� - Code:Any city or county which ruquire,,ennit toconstnIcLulteq
¢ rt ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO, ELEC. q Q 0
O o: requires the applicant for such permit In file a signed statement that TOTAL
ca n w m uc he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
Fzi Law(Chapter 9(commencing with Section 7000)ofErvision 3 ofthe '
a Business and Professions Code)or that he is exempt therefor,and QTY. PLUMBING PERMIT FEE qS
r m the basis fpr the alleged exemption.Any violation of Section malty RI Y YPE CO TR.
U, by any applicant lora permit subjects the applicant toacivil penalty ALTER-DRAIN&VENT-WATER IEA.) 5.00 •Y�I/l/•/SU//
of not more than five hundred dollars($5000.):
❑ I,as owner Of tire property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00
their sole compensation,will do the work,and the Structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and ProfessionsDRAINS-FLOOR,ROOF,AR EA, D. 5.00
Code:Tire 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 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such'in". e-
mentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
( or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 IEA ) 200 .+Y'u^"
builder will have the burden of proving that h - . - . .
e did not build or im- BUILDING USE
RES IND ON PB Omer
prove 1,aso nee of gale.). INDUSTRIAL WASTE INTER. � Woil ❑
❑ L as owner of the property.he exclusively. 7044,ting withEl 0
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.13 6.00 ASSESSO RCEL 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
tho Comructor's License Law. SEWER-SANITARY-STORM EA.2001010.00 TRACT NO. PARCEL NO-
❑ tum exempt under Sec,-,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACG FILE N0.
WORK 2RS'COMPENSA1 ION DECLARATION WATER TREATING EQUIP. 5.00 '
1 hereby affirm that 1 have a certificate of consent to self-insure. 20NING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance, r a certified
copy t heregf(Sec.3800,Lab.CJ.
Policy Nd. (('�Ct�vf/41Gwf11pany ,
Q ❑ Certil led copy shereby l'mms
Z Z4 FIRE SPO INK ENERGY T24
13 Certified copy n_Y filed wi h the cityspec
inspection division.
O Applicant /. nMISC.- REFER TO ORD. :!' YC] N[J Y ❑ NE]
MN CF-R11171CA'1'I!OI'I; z N11PION• ROM WORKIiRS' PERMITISSUANCE 10.00 FLOOD ZONE AL.U.C.
LU > COhIPI'-NSATION INSURANCE PLG.CONTR. LIC.NO. PLG.(
CL 0 nt
(this section need mol be coplaled if the permit is for one TOTAL Y NE] Y N�
hundred dollars IS 100)or le"r
U O I certify that in the performance of the work for which this per- OTV MECHANICAL PERMIT FEE FEE SUMMARY
U. F- mit is issued, I shall not employ any person in any manner so as to
O () become subject to the Workers'Compensation Laws of California
o_ Date Applicant ALTER.OR ADD TO MECH. 5.00 BUILDING
} W NOTICE 1'0 APPLICANT If,ulie,making this Certificate of fix-
� Z eruption,you should become subject to life Workers'Couipensation APPLIANCE .,,+5.00 PLAN CHECK
Provisions of tire r e LiduCode, you ,,all forthwith comply with �f FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10OWC .M.) 4.00
CONSTRUCTION LIiNDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 6.00 SEISMIC FEE s-y
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(See. MICROFILM
3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ,
Lender's Address ELECTRIC
1 certify that I have read this application andsate that the above VENTILATION FAN (SINGLE) 4.00
• information is correct.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating m building construction. and BOILER-OOMPO H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to 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 liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX ,
may in any way accrue against Said City in consequence of the
gaoling of this permit MECH.CONT. LIC.NO. MECH.
i TOTAL TOTAL
Signature o c t/C tract a 5
INSPECTOR COPY
at