C8654 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL Pig 1yrA 1)"q J0 of654
'O NER'S PLAN CHECK VALIDATION
NAME
O QTY. ELECTRIC PERMIT F,EE
•, 1\ n c c - R�H\�LOS NE
NAAMTRA OR se _'Te 4Y f -s s OUTLETS UTLETS-SWITCHES-RECEP 10.00/1.00 P,
N"'Y
' Drx - LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'
ADDRESS
PPLIANCES-RESIDENTIAL 4.00
S O I(
�`C �'A ONE,-?_77/ ( PANELS 10.00 DATE OF APPLICATION
ARCHITECT I 1 1. PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIc.ND. SIGNS TRANS. 3.00
AABC. OR DDRESS ENG, SPECIAL CIRCUIT 5.00 PERMIT VALIDATION '
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS
MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
'09 LICIiNSED COMIRACTORS DLCLARATION TEMP.POLE 30.00
¢ u v I hereby uflirnt that I mo licensed under provisions of Chapter 9 DE
NQ vai } (eco n en,in,with Section 7000)of Division 3 of the Business and BL G ELECT. PLG. MECH.
r• D z Professions Code,and my license is in full torce and effect.
,e0 as 1-mous,Class Lic.Number-i-� �I El
0 Z r Uute T_ 11( e Contractor.�{>r{:t,L -(}CSI
BUILDING PERMIT
¢ ¢ w u OWNER-BUILDER DECLARATION INFORMATION
w0 ec 1- I herebyfGrm that I air,exert t Gam the Contractor's License MISC.- REFER TO ORD
LLa p VALUATION $/FT.
F - o J Law fonheity.wingrity wh(Sec,703,5.ermit toccdProfessions PERMIT ISSUANCE 10.00
Code:Any city ar county which structure,
Damn to consua nL,also
Q ar 4 improve,dl'Inohsll,a!fl'pel!any SIIIICt UIC,prmr to I(S issuance,also ELEC.CONTR. LIC.NQ ELEC.
u w
- D ¢ requires the applicant for such permit to file a signed statement that TOTAL PE MIT TO
m m he is licensed pursuant to the provisions of the Contractor's License
Lie > Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe
< Business and Professions Code)or that he is ezempl therefrom and OTY. PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES/ TYPf O STR,
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred doll,rs(S500)J:
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 OCG 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,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and w ho does Such work FIXTURES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 1 NC.4 OUTLETS 6.00
or improvement is sold within one year of completion, - .the owner- GAS EASYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- ES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 El Ell ❑ 1:1❑ 1,as owner of the property,all)exclusively contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARC EL NO.
and Professions Code:The Contractors 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 contmctorls)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ l um exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACG FILE NO,
WORT;I?RS'COMPI7NSA'r1ON DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent[o self-insure,
or a Certificate of Workers'Compensation huumnce,or a certified ZONING ENG.SITE NO.
copy thereof(Sec 3800,Lab.C.).
Policy N.b3L&15-Cyr Su,�-�.m'�.� FIA&Ib
_ 0 ❑ Certified copy is hcreby_iRii had.
FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is Bled with the city inspectioni division. MISC.- REFER TO ORD.
Q Apphcam-6.p- Y ❑ N❑ V ❑ N❑
CERI'IFICA'I'E P HXEMPTION FROM WORK .RS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.u.c.
LLI > COMPENSWION INSURANCE PLG.CONTR. LIC.NO. PLG.
(This section need not be completed if the permit is for one TOTAL Y ElN❑ Y [:] N
Z ❑
hundred dollars IS 100)or Tess.)
U O I certify that in the performance of the work for which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any manner so es to
Ow become subject to the W'orkeri Compensation Laws of California. BUILDING
O_ Date Applicant ALTER OR ADD TO MECH. 5.00 -310
} N NOTICE'r0 APPLICANT: If,after making this Certificate of Ex-
F 2 emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
L) such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.NL) 4.00
CONS rRUCrION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 '
tire 3097 performance of the work for which this permit is issued ISec MICROFILM
HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's AddreHEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
ss
I certify that I have read this applieStion and state tint the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with,11 city and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-C OMP I3 H.P.Dr100,000S.T.U.) 6.00
hereby authorize representatives of this city lc enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCM. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree m save, indemnify and keep hornless 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
gran lg of this permit. MECH.CONT. LIC.NO. MECH.
DT"` TOTAL
16 anvco A
pplucantluouirrifictOr Date �✓. �/
INSPECTOR COPY -�