8643 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBFR
BUILDING APPLICATION & PERMIT g 643
ADDRESS
„20449r [jf 2.4A/ED 021�L BUILDING - ELECTRICAL-PLUMBING-MECHANICAL .
OWNER'S PLAN CHECK VALIDATION
NAME
. otei� ���M��//�jjJ�, CITY. ELECTRIC PERMIT FEE PPE1
//,bPHONE
CONTNAME OUTLETS
UTLETS-SWITCHES-RECEP 10.00/1.00 1(185
4 �f�0 �tilG LIC ND, 3' 3y ' LIGHTING FIXTURES D.DO/,.00 MpY 10 17
CONTRACTORS
ADDRESS 3414e PPLIANCES-RESIDENTIAL 4.00
(,7,pEay&1L ,5 71ls-7-100PANELS ,
. TECtl a p
0
OF APPLICATION
OPCH]TEcr PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADR. ENG. PERMIT VALID ON
ADDRESS
SPECIAL CIRCUIT 5.00
ZIP FEMP.METER ORP LE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADD Ess
" 9s' 7;f Y4 AV9, 01M SERVICECH NGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP.PO 30,00
a v U I hereby affirm Thu( 1 am licensed under provisions of Chupler 9 TSUANCETE
r
z w (commencing with Section 7000)of Division 3 of the Business and n ¢ a BLDG. LEGT. PLO. *MECm iProfessions s - den Icer Li is in full force' d f4tp1O m License Classes Lia Number / 3Y60 m r� Date s/C� Pr Contractor �OI . _ BUILDING PERMEl
¢ ¢ OWNISR-BUILUF.R DECLARATION
A a a u .INFORMATION
X g LL y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
LL o ¢
Low for the following reason.(Sec.7031.5.Businessand ProfessionspERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city or county which requires permit to construct,alter, -
am J ELEC.CONT9, LIC.NO.
re ¢o improve,demolish,or repair any structure,prior m its issuance,also ELEC.
DLL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n w m he is licensed pursuant 10 the ng with Section
of the Contractor's License ,t •�
H Z Q Law(Chapterand
Profession,
Code)or Section is exempt
the therefrom
and
tp/(Vl n(/.GA 1/rnV/t
4 D Business and Professions ern,t or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ H p the basis for the alleged exemption.Any violation t to action malty STOR 5 TYPE CONSTR.
a ; =' by any aenthntifor u permit subjects th500).)cam toacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollhrs($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.0 OCC.GROUP Res.UNITS
their sole coo pensalion,will do the work,and the structure Is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND.X.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
himsellor through his own employees,provided that such improve.
ffe
cuts are not intended or orect for sale.IL however,the building GAS-EA.SYSTEM-11NC.4OUT TS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 A.) 2.00
builder will have the burden of proving that he did not build or am- BUILDING USE
prove for purpose of sale.). INDUSTRIALWASTE INT 30.00 IND CON PB other
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ Cl
licensed contractors to construct the project(Sec. 7044,Nosiness LAWN SPRINKLERS-1 NC 5 V.B. 6.00 ASSESSORS PARCELNO.
and,Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLER OVER 5(EA.) 1.00
contracts for such projects witll a contractors)licensed pursuant to SEWER-SANITA -STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ lamexemplunder Sea ,B.&P.C.for this WATER HEAT W/VENT 6.00
reason
Owner Date WATER SV EM 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPE.NSATION DECLARATION WATER EATING EQUIP. 5.00
1 hereby infirm that I have a certificate or consent to self-insure, - ZONING ENG,SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800.Lab.C.).
Policy No. - Company
O ❑ Certified copy la hereby furnished. RE SPRINK ENERGY T 44
Z 2 R'Certified yq�� filet1� �th, t�e cit 'asp tion division.
Q Applicant yPJf4l1++�+� pZ MISC.- REFER TO ORD. Y❑ N❑ Y N❑
~ rn :.M •' PERMIT ISSUANCE 10.00
LU - CERT'11%CCOM OP EXEMPTION PROM WORKERS' FLOOD ZONE A.L.u.c.
W � COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL Z ITIO, section need not be completed if the permit is for one TOTAL 'Y❑ N❑ Y ElN❑
hundred dollars IS 100)or loss,)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
V become subject to the Workers'Compensation Laws of California.
a Dam ApplicantALTER OR ADD TO MECH. UILDING
} N NOTICE. TO APPLICANT: If,after making This Certificate of Ex-
F.Z emption.you should become subject 1.the Workers'Compensation APPLIANCE- 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4,00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IO,OODC.F.M.) 6.00 SEISMIC FEE
1 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.r HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and slate that tire VENTILATION FAN (SINGLE) 4.00
information is correct.1 agree to comply with all city and county PILL MBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to cater upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to 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
may in any way accrue a• inst mid City in consequence of the
gran'n o(Ihisp nti6 MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Si uture ol'Appli t/ ort or
Date {"�' /•-"' �V
OFFICE COPY
I