8452 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN•ONL-a'
BUI LDI NG PROJECT I DENTI FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
M/ 7 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S
8452
NAME /I^ - PLAN CHECK VALIDATION
JIO N - gvc, PRONE
CITY
ELECTRIC PERMIT FEE
CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC,NO, LIGHTING FIXTURES 10.00/1.00
A...FES TORS PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
oR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARC
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
_
ZIP TEMP. ME ER OR POLE INS. 20.00
APPLICANT ESS rs
ADOREss MOTORS ' SEE FEE SCH.
SERVICE CHANG _20.00
0 o LICENSED CONTRACTORS DECLARATION TEMP.PO E r 30.00
< u w I hereby.]'firm that 1 am licensed under provisions of Clmplcr
2 ISSUANCE GATE
I Professions
C with d rayl 700e i of Division 3 of the Business and t BLDG. ELECT. PLG. MECH.
° 0 w i Professions Cole,and my license is in full force and effect ❑ ❑\ ❑ ❑
z o m - License Class Lic.Number ^
z- ° 1I/
w Uale�_Cnnlmcfor
¢ ¢ w¢ OWNER-BUILDER DECLARATION '
BUILDING PERMIT
w °a ° MIS .- L' REFER TO ORD INFORMATION
3.LL H I hereby affirm that I am exempt from the Contractor's License
u o J Law for the following reason.(Sec 7031.5,Busimeseaud Professions VA WATION $/FT.
- PERMIT ISSUANCE 1p,00 W
�'^ Code:Any City or county which requires a permino conslmcf,alter,
1° PLEC.CONTR.. LIC.NO.
¢ ¢ ¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC. �p_rarr1�
A ° BE requires the applicant for such permit to file A signed statement that TOTAL V V
w ow he is licensed pursuanl to tf¢provisions of the Contractors License PERMIT TO
Hzi Law(Chapter 9(commencing with Section 7000)ofl)ivision 3 of tile
E i o Business and Professions Code)or that he is exempt therefrom and QTV. PLUMBING PERMIT FEE
¢ I-o the basis for the allege)exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a3 � by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dolls,(S50HJ:
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
sole compensation,will Jo the work,and [he structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,CON D. 5.00
Code The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT FLOOR AREA TOTAL ACREAGE
himself re of rote his own employees.Provided however,
such im building
hieans mself a through
or Offered eesale.lf,ed flud suhebuilding GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner-
builder will have the burden o1'proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE lu
prove for purpose of sale.). INDUSTRIAL WASTE INTER30.00 RES IND CON PB Omer
.
❑ I,as owner of the property,am exclusively contracting with 1:1 ❑ 1:1 1:1 El
contractors to construct the project(Sec, 7044,Business LAWN SPRINKLERS-1 INC$ 00 ASSESSORS PARCELNO.
and Professions Code:The Contractor's License Law does not apply V.B.. .
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 contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200f1/10.00
the C.m Ocw,`S License Law. TRACT NO. PARCEL NO.
❑ Ira xcmpl t d Sec. ,B.&P.C.for Ibis
on WATER HEATER W/VENT 6.00
Owner [)ate J WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORK FRS'&IPGNSATI DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of-consent tosch&fnstuv,
or a certificate of Warkers'Compensation Insurance,or a Ccrlilied ZONING ENG SITE NO.
copy thereof(Sce.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. RE SPRINK ENERGYTZ4
Z Z ❑ Certified copy is filed with the city inspection division.
FO Applicant MISC.- REFER TO ORD. V❑ NE] v ❑ NE]
M w CERTIFICATE OF EXENIPHON PRONI WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR.CL 0 LIC.NO,mPLG.
I Fhis .,firm need not be completed if the Permit is for one TOTAL Y❑ N❑ Y ❑ N❑
Z hundred doears15100)or less.)
U O .Yl certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
LLF-0 0 mitis:suede I shall not employ any person in any manner so as I,,O becomesubject to the WorkerF Contpen.tion Lawx of California.
y Dam Anplicanl ALTER OR ADD TO MECH. 500 BUILDING
>_ ED NOTICE '10 APPLICANT: If,after making this Certificate of Ex-
.
F Z vC Ption,you should become subject to the Worker: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 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm [hat 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.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify tour l have read this clinical.....and stale that foe above VENTILATION FAN (SINGLE) 4,00
information n correct. I s rel ti comply with all city and county PLUMBING
ordinances and orre laws reefing to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
hereby
coauthored property forinspo 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�jn any way accruenst said City in end
of[he
U
hag of thi permitMECH.CONT. LIC.NO. MECH.
\, ` h� -� TOTAL TOTAL
'JK Slgna[urc of Appli antra r [)at
e
INSPECTOR COPY