7283 r APPLICANT TO FILL IN INFORMATION WITHIN RED LINES'„ USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
PERMIT NUMBER
ADORESS APPLICATION & PER
MIT _ n^83
--�+ AODREss BUILDING -ELECTRICAL-PLUMBING -MECHANICAL rG
/obyl !/J. Est.,dt5 /I�
e ` OWNER'S PLAN CHECK VALIDATION
NAME !/ '] QT.Y. ELECTRIC PERMIT FEE
• COS µ / PRONE II�- •J<�I
coNTRAcrons UTLETS-SWITCHES-RECEP 5.00/1.00
r NAME 1 p
�JO�IS�{Q LIGHTING FIXTURES 5.00/1.00 £
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADDRESS
S31 k��C MAN !\�YHON[ o21J��s�I PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGN$ 6.UG PLAN CHECK FEE P.C.NO.
S OR
ENGINEER
LIC.No. SIGNS TRANS. - 3.00
ADDRESS ENG, PERMIT CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS b 3 1 Co taro fl n) oC MOTORS SEE FEE SCH.
ADDRESS
f,
5,7. CA 95116 SERVICE CHANGE 10.00
O O - LICENSED CONTRACTORS DECLARA"PION
a u w I hereby affirm that I am licensed under provisions of Chapter ISSUANCE DATE
(commencing with Section 7000)of Division 3 if tire Business and BLO EL PL MEGIf.
ry i Professions COI my I1'ecnse is in full force an�eflee
- License Class �R'pNn1'" Lia Number
9 H o f Dmc Contractor
a m E � BUILDING PERMIT
Q 2 w u 6WNER-BUILDER-R DECLARA-PION INFORMATION
o_ o A MISC.- REFER TO ORD
w 3 u I- hereby al'finn then I um exempt from the Contractors License VALUATION
H u o Q Law for the following reason.(Sec.7031.5,Itusinesswtd Professions PERMIT ISSUANCE - 6.00ve SIFT.
Code:Any city or county which requiresapermil to construct,alter. ELEC.CONTE. LIG N0.
improve,demolish,or repair any structure,prior to its issuance,also ELEG
G a, 'requires the applicant for such permit to file a signed statement that TOTAL�LJ- PERMIT TO
wm" he is licensed pursuant to tire provisions of tireContractor's License
r z i Law(Chapter 9(commencingwith Section 7000)of Division 3 alike SS��
4 Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE �� ..iI'O
K An
¢ c the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
u 3 8- by any applicant for a Permit subjects the aPPlic:mt to a civil penalty `
Of not more limn five hundred dollar,($500f): ALTER-DRAIN& VENT-WATER (EA.) 4,00
r ❑ I,65 owner o1'the'prmperty,or myen,plCyees with wages as BACK FLOW PROTECT. DEVICE t2.00 DCC.Group RES.UNITS
their sole ecmpenamlion,will do the work,and the 4ructure is not
intended or offered for sale (Sec. 7044, Business and I'micsOons DRAINS-FLOOR,ROOF,AREA,COND. '4.00 1
Code:'Che Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such wml FIXTURES-PER TRAP 4.00 50.FT.FLOOR AREA TOTAL ACREAGE
. himself or through his own employees,provided that such improve. -
ments me net intended or offered for Sale.If,however,the building GAS-EA-SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM. 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that lie did not build or IT- - . 5 IND LNG PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. - 20.00 r
O I;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. 5.00 ASSESSORS PARC EL NO.
and Professions fole:'I lie Contractor's License Law docs not apply
to mit owner Of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
"oro tends ctor'shcoueatswithmrommemrfsl licensed Pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL No.
-� tamR3,h,f for such
innsgLa w. '
❑ lam exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00 \
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 4.00
1 hereby affirm that I have a certificate of consent to self-insure. ZONING
or u certilicate of Workers Corepens tion Incurync• or a certificA ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.). !I S a Z)
-e•= Poli,N.._0...... . 5 RINE R•( AT79
7icdapy)S7 r' famished- FIRE SPRINK ENERGY T-24
z Z U'Crrti d (f s�{yy,d ��a l the r y inspection division.
Applicant r> �:%�7" ////% � / MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
F �- PERMIT ISSUANCE 6.00 /_ FLOOOZONE A.L.u.C.
fL - CfiRTl1'ICCOMPENSAIi.MPTINS RANGE NK B:RS' �.
CL 0 need not
be ION Afire PLG.CONTE. LIC.NO. PLG. '� V❑ N❑ Y❑ N❑
Z (I Ili, sectionCL 0 real nut be completed il' the permit is for one TOTAL/l/
hundred dollars IS 100)or less.)
U 0 1 certify that in the perfunnmee of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- Our is issued,I Shall not child"any person in any manner so as to 'N
U become Subject to the Workem''Compensmion Laws Of California. BUILDING
a Dale Applicant / ALTER OR ADD TO MECH. 4.00
} US NOTICE TO APPLICANI': If.after making this Certificate of Ex-
F_ Z cmption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.EM.) 5.00 SEISMIC FEE
I heroby aDinG tall Ibcm is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
tie performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.1. H EATI NG UN IT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 •'�
Lender's Address 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 with all city and county PLUMBING
ordinances and Stale laws relating to building construction, and BOILER-DOW(3 H.P.or 100,000 B,T.U.) 4.00
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, costa and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in anY sum accrue against s ' qty in consequence of the
gmnti "6f tNnnl MELHaCONT. LIG NO. MECH. ^�
TOTAL ter- TOTAL
grihture of Applicant/Contract Uate
INSPECTOR COPY