8330 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT_[DENT,[FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
P0400 Mari an i (Islipert J TIC) BUILDING-ELECTRICAL-PLUMBING -'MECHANICAL 8,330
,OWNER'a PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
• vnoNE
NAME acroRs UTLETS-SWITCHES-RECEP 10.00/1.00
BOLLS F u No. LIGHTING FIXTURES 10.00/1.00
ADDRESS oRs PPLIANCES-RESIDENTIAL .4.00
42 BZaC
Ont PANELS (OVER 200 AMP) 20.00OW PANELS 10.00 "
DATE OF APPLICATION I'
ARCXITECT ePLAN CHECK FEE P.C.NO.
m
OR
ENGINEER
uj�
c.No. SIGNS TRANS. 3.00 P
ARC H.OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00 JUN
ZIP EMP.METER OR POLE INS. 20.00 14 19
PPLfC85
ADDRESSTa MOTORS SEE FEE SCH.
r SERVICE CHANGE 20.00 City Of Cupertino
'. 02
0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
av I hereby affirm that I am licensed under provisions of Chapter 9 .
us a H (commencing with.Section 7000)of Division 3 of the Business and ISSUANCE DATE
OLD ELECT. PLG. MECH..
O H w z Professions Code,and my license b is in full force and effect � ` � ❑ ❑
0 i m o License Class C.-E;z_Lic.Number („I L1,111
v, H w Date-,4_q -b'y Contractor
Q y E j
a a w a OWNER-BUILDFR DECLARATION BUILDING PERMIT .
A O' D MISC-- REFER TO ORD INFORMATION
w 3 LL H 1 hereby affirm that I mn exempt from the Comracmr's License VALUATION g/FT.
cu o J Law for the following nvson.(Sec.7031.5,Businessand Professions 10.00 `
- PERMIT ISSUANCE
Code:Any city or county which requires a permit to is o4rael,,Mso
ar ¢ ¢ 0 improve,dmnoli,ah,or repair any slrtature,Prior l0 its is'mmncu,also ELEC.CONTR. LIC.NO. ELEC.;
IC u m a requires lite applicant for such permit to IIIc a signed statement tat TOTAL
w I PE
he is licensed pursuant to life provisions of the Contractor s License RMIT TO
Hit
Law(Chapter 9(commencing with Section 7000)of Division 3 offs,
f 4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE _
a H o the basis for the allege)exemption.Any violation of Section 7031.5 T S J.' /F
d 3 ^2 by any applicant for a permit subjects the applicant toacivil penalty
of not nmregtmn five hundred dollars($5000: ALTER-DRAIN& VENT-WATER (EA.) 5.00
4, I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 DCG GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of -
properlywhobuildsorimproves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLUOR AREA TOTAL ACREAGE
' • himself re of rote his own employees,provided that such improve- _
menti are raCTIt IS SOld w thin onefor
year
if.ompletion the the wilding GAS-EA.SYSTEM-1 1NC.40UTLETS 6.00
or improvement is sold within one year of completion of tbe owner-
- builder will shave the burden of proving that be did not build or int- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 t, BUILDING U E
prove l'Or purpose of tire.). RES INTI C - Other
❑ I,as owner of ale property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 El El
1 13
licensed contractors to emistruct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS ARCELNO.
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 Ii rsuch projects with a conlructons)licensed pursuunl to
the Contmcmr's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ l am exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00
reason
owner Date WATER SYSTEM 5.00
ACC.DATE ACG FILE NO.
WORKS RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I Imvc a cerlificate Of cttnsCut 10 sell-insure.
or a certificate of Workers'Compensation Insurance,or a certified 'ZONING ENG.SITE NO.
Copy thereof(Sce.3800,I-A.C.). p
Policy'NoIr"Dt':S fl9.6![,>hs�anY Sllyy_pl.lf.) v--ltb+t
O ❑ CCrll7and Copy is hereby(u nishe RE SPRINK ENERGY T-24
Z 2 a Certified copy is filed with the city inspection division. I N� V N�
Aps7llcmt MISC.- REFER TO ORD. YE]
CC Oy PERMIT ISSUANCE 10.00
LU - CERTIFICATE 017 EXEMPTION I PROM WORKERS' FLOOD ZONE A.LIILC.
W > COMI'F;NSATION INSURANCE PLG.CONTR. LIC,NO. PLG.
CL O IThis section need not be completed if the permit is for one TOTAL v❑ N y ❑ N�
G Z) Z hundred dollar,IS 100)orlcss.)
U O 1 certify that in the performance of the work for which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,1 shall not employ any person in any manner so us to
U become subject to the Workers'Compensation Laws of Culil'Orniu.'
y Date Applicant ALTER OR ADD TO MECH. 5.001 BUILDING
} rn NOTICE 'TO APPLICANT: If,after making this Certificate of fix-
F Z_ emprvisions of the Labor Code, you must forthwith comply with plion,you should become subject to life Workers'Compensation APPLIANCE 5.00 PLAN CHECK er
U sucoh provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MCF.M.) 4.00 FEE j
-s '
r� CONSTRUCTION LENDING ACFNCY AIR HANDLING UNIT(OVER IQOODC.EM.) 6.00 SEISMIC FEE
1 heraby affion tial 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.T H EATING UN IT(TO 100,000 B.T.U.) 8.00
Lender's Name -
Lender'sAddress HEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that l have read this application and state that the shove VENTILATION FAN (SINGLE) 4.00
•
information n correct. I agree to comply with all city"fi county BOILER-COMP13 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
Ordinances uhf state Iu ws relating c to building construction, unA
hereby autoDIc representatives of this city to enter 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 wPERMIT ISSUANCE hich CONST.TAXA
,. may in any way accrue against said City in consequence of the 10.00
granting of Ibis permit- MECH.CONT. UC.NO. MECH. i
TOTAL TOTAL'
a rt o ntraztor Uat � 73
if INSPECTOR COPY ,j
t/