8212 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES ='USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FI CATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS / �//��
O6O S 0 Z 041 ea br. BUILDING-ELECTRICAL-PLUMBING -MECHANICAL 82.12
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
,0 /1 e e-'0' !k6_k1 _r PHONE \
CONTRAF ORS
NA�`E ' .[/ OUTLETS-SWITCHES-RECEP 10.00/1.00
i - A c -ior OW OI(� uc.No.��7/Z/ LIGHTING FIXTURES 10.00/1.00
AD ACTORS PPLIANCES-RESIDENTIAL 4.00
AoOREss '/ / - �/
Stw C7,14t! / giriONE -72/ PANELS 10.00
DATE OF APPLICATION
OARCHITECT PANELS (OVER 200 AMP) 2000 PLAN CHECK FEE P.C.NO. /
ENGINEER
ry(y LIC.No, SIGNS TRANS. 3.00 I
ADDRESS ARCH.OR ENG./ SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
c ZIP EMP.METER OR POLE INS. 20.00
APPLICANT s
ADDRESS MOTORS SEE FEE SCH.
oREssl _
S�eA' Z SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a 0 Or I hereby flimn that I am licensed under provisions of Chapter 9 ISSUANCE DATE
G vw (commencing with Section 7000)of Division 3 of the Business and BLDG- ,ELECT. PLG. MECH.
H m z Professions Code,and my license is in full force and effect. ❑ •-❑`'ET Elz o License Class C- 4 Lie.Number i$7!/r D Date Contractor
02
Q Y f J
¢ ¢ 4 OWNER-BUILDER DECLARATION BUILDING PERMIT
o i 0 INFORMATION
X 3 LL N I heathy affirm Ihut I am exempt frons the Contractor's License MISC.- REFER TO ORD
u 0 a Law for the following reason.(Sce.7031.5.Huslnesuand Professions
VALUATION $/FT.
_ PERMIT ISSUANCE 10.00 -XitF
Code:Any city or county which requires a permit to construe,,alter,
Q IS 4 0 Improve,demolish,or repair any structure,prior to Its Issuance,also
ELEC.CONTR. LIC.N0. ELEC.
D ¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w$m he is licensed pursuant to the provisions of tire Contractors License
Hz >
Law(Chapter 9(commencing with Section 7000)of Division 3 of lire
a Rosiness and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ = the basis for the alleged exemption.Any violanon of Section 7031.5 /$EO B44ESJ1 9 TYPE�00r TR
a ; _ byanyapplicaniforapermitsubjectsth,appliconttOacivilpcnulty ALTER-DRAIN -WATER IEA.) 5.00 ')
of not more than five hundred allar,($500).)
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,tad the tmct.,c is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contrmtor's License Law does not apply t0 an owner of
properly 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 improve-
m
eats are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.INC.4 OUTLETS 6,00
or-improvement is Wild within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or an- BUILDING USE
prove for purpose ofsalc.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ 1,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. 6.00 ASSESSORS PARCEL NO.
and Professions Colic:The Contractors Lictraw Low does not apply
to an owner of properly 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 SEWER-SANITARY-STORM EA.200ft 10.00
the Contractors License Law. / TRACT NO.' PARCEL NO.
❑ I am exempt under Sec.-,R&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM t 5.00 ACC.DATE ACG FILE NO.
WORK F-RS'COMPF-NSATION DECLARATION WATER TREATING EQUIP. 5.00
I-hereby uffiral that I have a cc,titiezil,ol'conwnt to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy Ihereof(Sec.3800,Lab.C.),
Policy No. Cgrnpany -
O ❑ Cerbhe a>p'is hereby l'urnis� J e FIRE SPRINK ENERGYT24
Z Z L; Certified copy is filed with the city inspection division.
O Applicant c�"5G MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
X w CERTIFICA FE OF IiXF-MPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR, ❑C.NO. PLGCL 0 .
Z (This section necJ not be completed if the Permit is for one TOTAL Y❑ N❑ V ❑ N❑
hundred dollars(S 100) Oless.)
U O I Certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY -
LL I- mit is issued,I shall not employ any person in any Inanner so as to
O L) become subject to the Workers Compensut ion Laws of California.
o. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING 7// SO
} to NOTICE: 'f0 APPLICANT': If.after making this Certificate of Gs- 'f�
F ? Caption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor COLIC, you amsl Forthwith comply with FEE /,6- 3
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10fMC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MIC.F.M.) 6.00 SEISMIC FEE 0 . 6
1 hcrchy uffinn that then, is a Construction lending,gency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). I 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
I cerlily that I have read this application andstale that 111,ahuve VENTILATION FAN (SINGLE) 4.00
information corner 1 agree to comply with all city and county BOILER-COMP 13 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to Cater upon she
ubov0-mentioned property for inspection purpoBOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
ses.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against id Cit at consequence of she PERMIT ISSUANCE 110.00
gmnipg of clillit. MECH.CONT. LID.NO. MECH.
10.757 DTAL TOTAL 1123,576
Signature Apr hcaln/Contractor Date ,x
INSPECTOR COPY x
t