C8708'! APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDING PROJECT IDENTIFICATION PERMIT NUMBER
( BUILDING APPLICATION & PERMIT
Y ADDR7117
55/ / ��
//�D BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 8708
OWNER'S ///\\\--- PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE ]
APHONE
Came ACTORS / OUTLETS-SWITCHES-RECEP 10.00/1.00 ti
LIC.No. LIGHTING FIXTURES 10.00/1.00 zU
f-ONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT
OR PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0.
ENGINEER
LIC.No, SIGNS TRANS. 3.00
ADDRESS ENG
SPECIAL CIRCUIT 1 5.0Q t PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
02 LICENSED CON TRACTORS DECLARATION TEMP.POLE 30.00
To v p I hereby aIlimd that 1 am licensed antler provisions of Chapter 9 ISSUANCE DATE O 11
w (mm..nancing with Section 7000)of Division 3 of the Business add
a m BLDG. ELECT. PLG. MECH,
r y z Pro sCha Cade,and my license is in fill force and effect.
0 O�, - License) (, Class Con Number
g 2 r�- Datc Contractor
a Y E El El El
BUILDING PERMIT
¢ ¢o i OWNER-BUILDER DECLARATION INFORMATION
F
; LL m I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
LL04 law forthe following reason.(Set,7031.5.Business and Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
� - Code:Any city or county which requires a permit construct,
¢ wELEC.CONTR. LIC.NO. d
¢ Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.
a wD LL requires the applicant for such permit to file a signed slalem nt that TOTAL PERMIT TO
m he is licensed pursuant to the provisions of the Contractor's License `
I_ i s, Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Nosiness and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE /'/L:-7 / //O'N/
¢=$ the basis for the alleged exemption.Any violation of Section 703
malty STORIES TYPE CONSTR.
a ; _ by any applicant for a permit subjects Om applicant toacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not ,In.than five hundred dollars 145001.1:
` O I,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 cul OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 _
Code:'file Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE
• 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-l1NC.40UTLETS 6.00
or improvement is sold within one year of completion'
the owner- GAS EA. OVER 4(EA.) 200
builder will have the burden of proving that he did t b - . - . .
imuild or - BUILDING USE
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 3000 RES IND CON PB Omer
EI 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.8. 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 thercon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contructorls)licensed pursuant to SEWER-SAN EA.200ftI10.00
the Contractor's License Law. TRACT N0. PARCEL NO.
O Ian exc prnr B.b.P.C.for this WATER HEATER W/,VENT 6.00
reason
k Owner Uate - WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO. '
WORKF:RCOMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm it 1 have a certificate ofconsent to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(See.3800,Lab.C).
Policy No. Company
O Cl Certified copy is hereby famished. FIRE SPRINK ENERGY T-24
,Z Z ❑1'C-ertified copy is fled with the city inspection division.
0 Applicant MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
Crw - CERT IFICATE OF Ii XEMPTIGN PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOOZONE A.L.U.C.
LL > COMPI,NSATION INSURANCE PLG.CONTR. LIC.NO. PLG. v❑ N❑ v❑ N[_
� .
0 (Phis section need not be connpleted if the permit is for one TOTAL
hundred dollars IS 100)or Ica.) -
U 0 1 r,til'y that in Ole 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 as to
Ow s
bccmocildest to theoG,krri Compcm,mion Lawso(California.
d Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} m NO1 IC17 TO APPLICANT: If,alter making this Certificate of Ex-
j F. ? mnption,you should become subject to tie Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10DMC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000GEM.) 6.00 SEISMIC FEE S
I 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.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC (�
Address �
Landcr's
I certify that 1 hwe read this application and stat,that the above VENTILATION FAN (SINGLE) 4.00 '
inl'orncntion is correct I agree to comply with all city and county. PLUMBING
ordinances and state laws relating to building action, and BOILER-COMP(3 H.P.Or 100,0008.T.U.) 6.00
hereby authorize representatives of this city tocontrenter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL OO
above-mentioned property for inspection purposes.
(we) agree to one, indemnify and keep harmless the City of MISC.- '' REFER TO ORD.
Cupertino against lia i ,ju 1, osts and expenses which PERMIT ISSUANCE 10.00 µ. CONST.TAX
Amy in any w ' wins said L, y in consequence of the
9 tL MECH.CONT. LIC.NO. MECH.I
• �- rorALe /�_� TOTAL ,3 9ign of Appi nl/Contactor )ate
... INSPECTOR COPY '
1_