8339 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT ^
ADDRESS
i BUILDING - ELECTRICAL-PLUMBING-MECHANICAL i�.'
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
1 vroNE
IonsI NNAAMERAcrO s C-/ p OUTLETS-SWITCHES-RECEP x.00 /
S' 11C.No. 99 LIGHTING FIXTURES .00
Arops� PPLIANCES-RESIDENTIAL 4.00
ADDRESS S g'O�/ C.(Jr N ft t1.D �Y,V�
PHONE _ PANELS 1 !�A DATE OF APPLICATION
ORc rc6cT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE PC,No.
ENGINEER
LIC,NO. SIGNS TRANS. 3.00 1
ADDRRiSS ENG, SPECIAL CIRCUIT 6.00 It PERMIT VALIDATION -
nv EMP.METER OR POLE INS. 20.00
APPLI MOTORS SEE FEE SCH.
S
ADDRDOR ESS
SERVICE CHANGE 4
wo LICENSED CONT RACTORS DECLARATION TEMP.POLE 30.00
mao w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
2 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. ❑ ❑ ❑
o w- License Class Lia Number
Date �-� 1 � G�
a -_ w - '7Q -b Contractor/c;�y�,_U.pi __
¢ Y s L-'lp-cM(C BU DING PERMIT
¢ ¢O a o OWNER-BUILDER DIiCLA RATIOS
04FORMATION
E
3 u H I herchy of tion Thal I sat exempt Imo the Convector's License MISC.- REFER TO ORD
F ¢ Oj Law for the following reason.(Sec.7031.5.lidsinessand Professions PERMIT ISSUANCE 10 VALUATION $/FT.
Code:Any city or coumy which requires a permit m construct,alter,
¢ ¢¢ o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEG -/
ic requires the applicant for such permit to file a signed statement that 3 TOTAL / PERMIT TO
n w m m he is licensed pursuant to the provisions of the Contractor's License _ r
rzQ Law(Chapter9(commencing with Section 7000)ofDivision 3 ofthe
i G business and Professions Code)or that ho is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES - PE CONSTR.
e- tut by any applicant fora permit subjects Ore applicant toacivil penalty ALTER-DRAIN (EA.)of not more than five hundred dollars($500).):
❑ 1,as owner of fire 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,AR EA,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 so.FT.FLOOR AREA TOTAL ACREAGE
. himself re through his own employers,provided thus such im building
hicuts mself a not through
oncoffered for Sale.If, that net, budding GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion, - . -OVER 4 IEA. .00 the owner- GAS EASYSTEM ) 2
builder will have the burden of proving that lie did no[ the
or im- BUILDING USE
prove for purpose of sale.). RES IND CON ,PB Other
❑ I,as owner of the property,cin exclusively contracting with
INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
licensed contractors In construct the 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 of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a coniractous)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
❑ lam exempt under Sec. ,B.&OC.for Ibis WATER HEATER W/VENT 6.00
reason
owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK F-RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate it consent to sail'-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance or a certified
copy thereof 1Sce.3800,LaRCJ.
Policy No. Company
O ❑ Cer�t1led copy is hereby furnished.
- - �1 FIRE 6PRINK ENERGY 24
'Z 2 pKmlttiCied drpy is filed with the city inspection division. MISC.- REFER TO ORD.
O nnF�llr'ant yni Boa 1.4f2c 6y C'I.Cr}Y>`F6' Y ❑ N❑ v ❑ N❑
~ w PERMIT ISSUANCE 10.00
� - CERTIFICATEOFNSAEIOTINS FROMWORKERS'KERS' FLOOD ZONE A.L.0 C.
W > COhll'IiN$A1'ION INSURANCI! vLG.CONTR. LIC.NO. PLG.
Z fThis section need not be completed if the permit is for one TOTAL Y❑ N❑ Y F] N[]
O hundred dollars IS 100)or less.)
I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued, I shall not employ any person in any manner so as to
0 W become subject to the Workers'Compensation Laws of California.
a Ualc Applicant BUILDING
>_ N NOTIC17 TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
F 2 eruption,you should become subject to the Worken'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you ruost hollovith comply with FEE
U Such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO I0=C.F.M,) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
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(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 800
Lenders Name HEATI NG UNIT 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application andstate that the above VENTILATION FAN (SINGLE) 4.00
• information is correct. 1 agree to comply'with zll city and county PLUMBING
str
ordinances and state laws relating to building conuion, anJ
esBOILER-COMP(3 H.P.or 100,0008.T.U.) 6.00
hereby authorize representatives of this city to cn lect
r upon the BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purpos .
(We) agree m 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
in any way accrue against Said CityI in consequence of the
,,an •of thi permit I'V Vk 6717 / t1 b21YL( L MECH.CONT. LIC.NO. MECH.
- TOTAL TOTAL /
g rite o L rh1@b or ate
INSPECTOR COPY
I