8599 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT IDENTIFICATION PERMIT NUMBER
AUILOADDRESS APPLICATION & PERMIT 8599�^^
IN 4.! lOJ l!
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL U a3
O E - PLAN CHECK VALIDATION
oNAME OTY. ELECTRIC PERMIT FEE-
NAMEJITR L OUTLETS'-SWITCHES-RECEP 10.00/1.00
Ic.rvo. 6 ( LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'SPPLIANCES-RESIDENTIAL 4.00
ADDRESS/_/-/_O I)F VOLAS IRF �P
vRONE q PANELS 10.00 DATE OF APPLICATION
ORRCRITET - 1 PANELS (OVER 200 AMP) 2000 PLAN CHECK FEE P.C.NO.
ENGINEER
UC.No. SIGNS TRANS. 3.00
ADDRESS ENG. PERMIT CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 20.00
ASMOTORS SEE FEE SCH. J
ADDREDDRESSS
SERVICE CHANGE 20.00 (' _
0 0 o LICENSED CONTRACTORS DECLARATION TEMP,POLE 30.00
F i W I be obs affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
v,iQ A (commencing will,Section 7000)of Division 3 of the Business and BLDG. ELECT. I PLG, MECH.
H w i Professions Code,and my license is in full force and effect ❑ ❑ ® ❑
z o m - License Lie.Number+=18
D m H DContraclor �F1y,w,
{ a x E �' c� -JJ BUILDING PERMIT
ar o a u OWN lilt-RUILDER DECLARATION INFORMATION
X S'L I hereby affirm that I am exempt from the Co
mmctor's License MISC.- REFER TO ORD
uoj Law for the following reason.(Sec.7031.5.tlusinessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
� - Code:Anycity orcounty which requires a permit to construct,alter,
ic rc Q improve,demolish,or repair any slReture,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
ia O Q requires the applicant for such permit to file a signed statement that TOTAL
u w se he is licensed pursuant to the provisions of the C....tractor's License - PERMIT TO
Hai
Law(Chapter 9(commentingwithSection 7000)ofDivision 3oftile ?LBC,
4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
2 h- o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
wm 3 by any applicant for a permit subjects the applicant to a civil penalty 1 ALTER-DRAIN St VENT-WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the.work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:'Phe Contractor's License Law does not apply to an owner of
1 property who builds or improves thereon,and who does such work FIXTURES-PER TRAP S.OD SO.FT.FLOOR AREA TOTAL ACREAGE
o himself or through.his own employees.provided that such improve-
elects are not intended or offered for sale If,however,the building GAS-EA.SYSTEM-1 OUTLETS 6.00
or inlprovemenl is sold within one year of completion, - . - . .00 the owner GAS EASYSTEM OVER 4 IEA) 2
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ 1,as owner of the property,am exclusively contracting wish ❑ ❑ ❑ ❑ ❑
licensed contractor, to 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
cmnmels for such Prnjects with a contructous)licensed pursuant to SEWERSANITAR V-STORM EA.200St/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under See ,B.SP.C.fol this WATER HEATER W/VENT 6.00
reason
Owner Dale WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKI:RS'COMPFNSAI ION DECLARA'I ION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consentto self-insure, x ZONING ENG.SITE NO.
or a certificate of Workers'Compensation or a ceCompensation Insu rtified
copy thereof(Sec.3800,Lab.CJ. 1
Policy No�,[��Company I_
O ❑ Qv IF � npyl is hereby furnuhe RE SPRINK ENERGYT 24
z Z ❑ Certified ;t,:y is fated ith the city inspection Jivi,io..
O 'Applicant �{�.�g -P MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
~ w PERMIT ISSUANCE 10.00
LU f,IiRTIFIGO!1i PF EXEMPTION FROM WORKERS' FLOOD ZONE a.I.U.C.
W COMPBNSAT'ION INSURANCE PLG CONTR, LIC.NO. PLG. ^(�,
d O ('Phis wdlon need net be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
::) Z hundred dollars(S 100)or less.)
U 0 1 certify that in the performance of the work for which this per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY
W H mit is issued,1 shall not employ any person in any nhanner so as to
O W become subject to the Workers'Compensation Laws of California.
y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} va NOTICE TO APPLICANT: If,after making this Certificate of Ex-
Z emPliou,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10)000C.F.M.) 4.00
CONSIRUCION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that Imre is a construction lending agency for If EXHAUST HOOD(WITH DUCT) 5.00
the performance of tel work for which this permit is issued(Sec , MICROFILM
3097,Cfv.C.), HEATING UNIT(TO 100000 B.T.U.) -8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
1 certify that I have read this application andstate that the above VENTILATION FAN (SINGLE) 4.00 t
information is correct I agree to comply with all city and county PLUMBING
ordinunces and state laws relating In building cmutruclion, unA BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby mtlmrize representatives of this city hat enter, upon the
ubove.rnentioned property for inspection PerpnBOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
sns.
(We) agree to Save• indemnify and keep harmless the City is MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way acerae against said City in consequence of the
granting of this permit MECH.CONT. LIC.NO. MECH.
\ /0-^ '(J �K TOTAL TOTAL
�C Shgrimo, f�ca C�ractor D le
INSPECTOR COPY x