C8730 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
ADDRESS
It)
APPLICATION & PERMIT 8730
AIO 007-#/6D
GJ ° PG t_VBUILDING — ELECTRICAL—PLUMBING—MECHANICAL
OWNER'$ I PLAN CHECK VALIDATION
NAME
OTY. ELECTRIC PERMIT FEE
A10/V ' 5_W91VS01V PHpNE2.5'7-SCy?
CONTRACTORS
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
5W1f1VSoti UCNO. OVIV LIGHTING FIXTURES 1"101.00 GU �kjQl
CONTRACTORS APPLIANCES 4.00
ADDRESS �r �p L �7
'• ° 0 11cN UT 1-1/1 ZYHONE Zp/— Q PANELS DATE OF APPLICATION
OR
ARCHITECT PANELS OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
�.• ENGINEER
° if•SGUIfA10 RJ UC.NO. SIGNS TRANS. 3.00
AARC
DDRH OR ESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
/(" ZIP EMP.METER OR POLE INS. 20.00
AP IESS MOTORS SEE FEE SCH. - '/'�1
ADDRESS \ 'J/J
41 4f(� SERVICE CHANGE 20.00 (/J`/f^/{�y/ P�j I
,- 02
0 0 LICENSED COM—RACfORS DECLARATION TEMP.POLE 30.00 W 6/J J 0 f
a U v 1 hereby of irn that I am licensed under provisions of Chapter 9 ISSUANCE DATE
• FA a u z w from ntenmng wish Section 7000)of Division 3 of the Business and
BLDG. ELECT. PLG. MECH.
y i Pro l'cssions Coda,and my license is in full force and effect. ®.
a z m W License Class Lia Number .�
Date Contractor
a y E BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
A o a U INFORMATION
w 3 LL I hereby affirin that I am exempt from the Contractor's License MISC.— REFER TO ORD
VALUATION $/FT.
F ¢ Oa Law for Om following reason.(Sec.7031.5,BusinessanJ Professions PERMIT ISSUANCE -1,0,00. "JVor
Any city or county which requires.permit to construct,.lie,, _
Qu, Q improve,demolish,of repair any structure,prior to Its issuance,dlSo ELEC.CONTR. LIC.NO. ELEC. O QO 7
O LL requires the applicant for such permit to file a signed statement that TOTAL o PERMIT TO
a w m Ire is licensed pursuant to the provisions ol'thc Contractor's License _
F Z Q Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
i O Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ m the basis for the alleged exemption.Any violation of Section 703 LS STORIES PE CO R.
d3 _ by any applicant fora permit subjects the applicant lou Civil penalty ALTER-DRAIN -WATER IEA.) 5.00 S /✓, pR
of nm more w than e five the prop dollars(my em):
❑ Las owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole r offered
compensation,will(S the work,and the structure is nos
intended or offered for sale(Sec 7044.does
Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's improves
Law does not apply to an owner of F
property who builds or improves employees.
pr and who does such work FIXTURES-PER TRAP C,(�(� UL
forms Or of rote did own lferedl for sale.proSaid ho that ritch Illlprove- .MW✓ SD.FT.FLOOR AREA TOTAL ACREAGE
meimprovmentiun old or wthin one yearo l f,however,the budding GAS-EA.SYSTEM-11NC.4OUT LETS � Dor & /
or improvement is sob within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or ire- BUILDING USE
Prove for purposeofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PS Other
❑ 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.8. 6.00 \ ASSESSORSPARCELNO.
and Professions Code:The Contractor's License Law docs 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 contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.2001t/1b00TRACT NO. PARCEL NO.
O lure exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT IS=
reason
.r Owner DateWATER SYSTEM 500 r ("0ACC.DATE ACC.FILE NO.
WORK ERS'CONPESNSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO-
copy thereof(Sec.3800,Lab.Q).
Policy No. Company
0 ❑ Certified copy is hereby furnished.
Z Z ❑ Certified copy is filed with the city inspection division. FIRE SPR INK ENERGY T-Z4
I—
ON— Applicant MISC.- it REFER TO ORD. YE] N❑ YF] N❑
PERMIT ISSUANCE (h
W CERTIFICATE OF
NSURANN FROMCWORKISRS' PLO.CONTR. UC.NO. I.G. Dn ^ ,�, FLOOD ZONE A.L.U.C.
7D Z (Phis section need not be completed if the permit is for One TOTAL �G/ V N� Y No
hundred dollars($100)or less.)
0 O I certify that in the perform:ace of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL i— mit 0 issued, I shall not employ any person in any manner so as to
0 U become subject to the Workers'Compensation Laws ol'California.
w Dae Applicant BUILDING
a ALTER OR ADD TO MECH. 5.00 i OO
} to NO'DCI?TO APPLICANT: If,after making this Certificate of Ex-
2 enlption,you should become subject to the Workers Compensation APPLIANCE 5.00 / PLAN CHECK
provisions of the Labor Code, you mug forthwith comply with -t FEE
U such provisions or His permit shall be deemed revoked. AIR HANbLING UNIT(TO 10)MOC.F.M.) 4.00 s
CONSTRUQI'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE G !/ r
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the perf onnanec of lite work for which this permit is issued(See. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 10d.000 B.T.U.) 8.00
Lender's Name H EATI N G U N IT(OVER 100,000 B.T.U.)9.50
Leader's Address ELECTRIC
I C
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 Met
information is correct. I agree to comply with all city and countyPLUMBING --
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P_or 100,060 B.T.U.) 6.00 n
hereby authorize representatives of this city toenter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE-SCH. MECHANICAL
aboveQ 7
mentioned property for inspection purposes.
(We) agree to Save, indemnify and keep harmless the City of MISC.- a a' REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX "y
may m any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 iG1.C� _ / /
grant g of this permit. MECH.CONT. LIC.NO. MECH. F "
5 TOTAL d 7Ov TOTAL /O��G
n man I actor a z
INSPECTOR COPY
:S 4�