C8634 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
.BUILDING PROJECT IDENTIFICATION vERMIT NUMBER
BUILDING APPLICATION & PERMIT ����e
TUILDIN 4
BUILDING -ELECTRICAL-PLUMBING -MECHANICAL
OWNER"
NAME
IN CHECK VALIDATION
. CITY. ELECTRIC PERMIT FEE
PHONE '141
C NTRACT q's
NAME CPj3_ OUTLETS-SWITCHES-RECEP 10.0011.00
AoNMA0L61;le TIC NO. LIGHTING FIXTURES 10.00/1.00
DD SS oR 2255 CAMDEN A✓EN PPLIANCES-RESIDENTIAL- 4.00
Q67 Zd PHONE 3T71.grkno PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR NA.Q[.CS T. AO�JMS PANELS (OVER 200 AMP) 20.00 Fy
Llc.No. SIGNS TRANS. 3.d0
AT CH OR ENS L ,J 1.I1I�fKNlT(l� SPECIAL CIRCUIT 5.00 �'� PERMIT VALIDATION
ADDRESS l
L zIv EMP. METER OR POLE INS. 20.00
AS " A
ADDREDDRESSS MOTORS 2SEE FEE SCH.
SERVICE CHANGE 20.00
O o LICENSED CONTRACTORS D17CLARATION TEMP.POLE 30.00
<'z
in C, I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
N (commencing witli Section 7000)of Division 3 of the Business and
¢ n N BLDG. ELECT. PLG. MECH.
H i Pfofesslms Codc, ly license is in full for effect �L„ .� >?y,O-
r�ooL t¢ ❑ ❑
z O w - License Class Lie.Number, ❑
9 H1H °w Dale Contra
¢ x sJ Y BUILDING PERMIT
¢,O IF <i U WNIiR-BUILDER DL AR 'PION w ` INFORMATION
w ;.¢ F. I hereby affirm that I am exempt from m Contractor's License MISC.- REFER TO ORD VALUATION
n O¢ Law for the following ceawn.(Sec.703 L5,Uusiness and Professions PERMIT ISSUANCE �,pQ G p'G S/FT.
� - Code:Any city orcounty which rc9uiresa permit loconstnmt alter,
¢ ¢¢ a improve,demolish,or repair any stnceture,prior to its issumme,also ELEC.CONTP. LIC.N4 ELE(L �/ 7-i
a wCI ¢ requires the applicant for such permit to file a signed statement thatAIVA TOTAL r/y G PERMIT TO
m " he is licensed pursuant to the provisions of the Contractor's License n
wz0 Law(Chapter 9(commencingwith Section 7000)of Division 3 of the Uwi^•YH i'L/�r' �dd
4 O Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
IS I- o the basis for the alleged exemption.Any violation of$ection 7031.5 STORIES TYPE CONSTR.
aim by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five II undred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEV ICE 4.00
their who compensation,will do the work,and the structure is not OCG GROUP RES UNITS
intended or offered for sale(Sec 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 '
.Code:The Contractors License Law does not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-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 budding GAS-EA.SYSTEM-1 INCA OUTLE 6.00 .vp
or inlprosennent is sold wilhin one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving thin he did not build or ire- BUILDING USE
prose for purpose ofsaleJ. NDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,as owner of the property',am exclusively contracting with ❑ ❑ ❑ ❑ ❑,
licensed contractors to construct the project(Sec. 7144,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
contracts for such projects with a contractons)licensed pursuant to SEWER-SAN V-STORM EA.200ft110.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec.-,BARC.for this WATER HEATER W/VENT 6.00
reason
Owner L1.v��r/�'���..,/.yy �77��� Date WATER SYSTEM 5.00 OT.
'WiJRICF':2S"CO� -VSXP WATER TREATING EQUIP. � 5.00 a� ACG PATE ACC.FILE NO.
1YL� ION DECLARATION ,vQ
Zv
rc.py
eby affirm that I have a certificate of consent lo self-insure '� ZONING ENG.SITE NO.
rt ifirde of Workers'Compensation Insurance or a certified
ereof(So .3800,Lab.C.).�""',. r ,aL,6 f e etn 1 O '
Company ,
0 died copy is hereby frills e -FIRESPRINK, , ENERGY T 24 .
S Z ZO A6, "c'
'•d-- py is Bled with the city insvecti divi MISC- REFER TO ORD. p. v N v N
❑ ❑ ❑ ❑
� PERMIT ISSUANCE 10.00
CGRI IC TE OP L\IJA PTION PNOM1 WORKIiNS' FLOOD ZONE A.L.U.C.
W COMI'1�NSATION L SURANCL PLG.CONTR. C.NOP PLG. (jl.
Z (This section need not be completed it the permit is for one _ TOTAL q is -- V❑ N❑ v❑ N❑
hundred dollms(S 10(1 or Icss.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT , FEE FEE SUMMARY
IL U mit is issued, I shall not employ any person in any manner so as to
beCOne subject to the Workers Compensation Laws of California.
UJ Uuw Applicam BUILDING / 7j
} W NOTICE TO APPLICANT: If,after making this Certificate of lis- ALTER OR ADD'TO MECH. 5.00 S
♦- Z 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
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION L17NDING AGLNCY AIR HANDLING UNIT(OVER 10=C.E.M.). 6.00 SEISMIC FEE / /J
I hereby ufl'irm HIM there is a constructionlending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which'ihis permit is issued(Sec. MICROFILM
3097,Civ,C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Nene1
Lender's Address EP'� / HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC U rti
I certify Hurt 1 have read thisappli anion and state that the above VENTILATION FAN (SINGLE) 4.00
indimin,on n correct, 1 , el to comply with all city and county _ PLUMBING q
01,
ordinances and state I I agree relating to ly with construction, and BOILER-COMP13 H.P.or 100,000 B.T.U.) 6:00 p( /e
hereby authorize representatives of this city to enter upon the BOILER-COMP SZ MECHANICAL 7
abovomeniio authorize
property for inspection purposes. ,-
(We) agree to save, indemnify-and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgmerits, costs and expenses which PERMIT ISSUANCE\ 10.00 pp CONST.TAX I
mry in any way accrue against id City 1 cunsequemcc-of the pr
gran ' • this permit MECH.CONT. LIC.NO. MECH.
Sisn t/ a / ' aur ale C,53 TOTAL /7� TOTAL /� /v
INSPECTOR COPY