8347 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS B _
/ 3347
BUILDING — ELECTRICAL—PLUMBING—MECHANICAL
OWNER'S PLAN CHECK VALIDATION
cNAME btire.�D44 On�1xQTY. ELECTRIC PERMIT FEE
U ONE
UTLETS-SWITCHES-RECEP 10.00/1.00
NAME ME
Lc.NO. LIGHTING FIXTURES 10.00/1.00
R yrb APPLIANCES-RESIDENTIAL 4.00
ADDRESS U
" PHONE PANELS 10,00 DATE OF APPLICATION
rtE
AR HCTV ,Alp 14 PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIc,No, SIGNS TRANS. 3.00
ADDRESS EN SPECIALCIRCUIT 5,QQ PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS, 20.00
APPLI CANT
ADDRESS S MOTORS SEE FEE SCH.
N.
7 _ \ SERVICE CHANGE 20.00 r
I:o ' neCLAR TION TEMP.POLE
LICIiNSIiD CONIBACTORS 30.00 J
I hereby atl'inn that 1 am licensed under provisions of Chapter 9 ISSUANCE�DttTE
(commencing with Section 7000)of Division 3 of tire Business and BLDG. ELECT. PLG. MECH.
F.D i Professions Code,and my license is in full force and effect ❑
2 o m — License Class Lim.Number_�q� ❑ ❑
r UuIn� Contractor_ F -
IS Y E 4 BUILDING PERMIT
IS w ¢ OWNER-BUILDER DECLARATION INFORMATION
o a O MISC.— REFER TO ORD
w ; LL y I hereby uftirm that I am exempt from the Contractor's License VALUATION $/FT.
r l. oa Law for the l'olluwing reason.(See.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
Click:Any city or county which requires a permit to construct,alter,
rt ¢ < improve,denmlish,or repair env structure,prior to its issuance,also ELEC.CONTR. I.C.NO, ELEC.
ic ¢ requires tire applicant for such permit In file a signed stat emenl that TOTAL PERMIT TO
w m IL he is licensed pursuant to the provisions o1'the Contractor's License
HZi Law(Chapter9(commencingwithSection7000)ofDivision3rfthc >v�36-
¢ Business mrd I'rofessfons Code)or that he is exempt therefrom olid QTV. PLUMBING PERMIT FEE
¢ F o the basis for Lire alleged exemption.Any violation ol-Section 7031.5 - STORIES TYPE CONSTR.
a32? by any applicant for a per it subjects the applicant o a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(55001.1:
O 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do Ore work,and the structure is not
intended or milled for sale (Sec, 7044, Business:.lid Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of /gyp
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP ywv SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- 0UTL TS 6.00 +
ments are not intended or Offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4
or improvement is sold within one year of completion, - . .) 2.00 the owner- GAS EASYSTEM-OVER 4 (EA
builder will have the minden of proving that he did not build or im_ BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ _I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to cDrl oneir the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
andProfessions Code The Contractor's License Law dues not apply
to un owner of property who builds or improves thereon.and who LAWN SPR IN KLERS-OVER 5 (EA.) 1,00
contracts for such projects with a contractors)licensed pursuant to , SEWER-SANITARY-STORM EA.200ft/10
the Contractors License Law. TRACT NO, PARCEL NO.
❑ l um exempt under Sec. ,B.dip,C.for this WATER HEATER W/VENT c 6.
Cb
reason
Uwncr Date WATER SYSTEM 5_0,0 41 flL ACC.DATE ACC,FILE No.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5A0
1 hereby affirm that I have a certificate of consent to self-insure, ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy tire...)J(Sec.3800,Lah.CJ.
Policy NYO —P"N_Y d*T`g7
O ClCerlifede_'o}ry'is hereby turn, e . FIRE SPRINK ENERGY T 24
"Z Z ❑ Certified cup, is tiled will the city inspeclio�n�d1iv�ision. MISC.- REFER TO ORD.
O Applicant ti - 11.1 r� Y❑ N❑ Y ❑ No
� y CF:R'1'1171CAT'E OP BXEMPTIO PROM WORKERS' PERMIT ISSUANCE 10 FLOODZONE ATUA.
LU > COMPENSAT'ION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This section need not be completed if the permit is for one 1 TOTAL z2- Y❑ NO Y❑ N❑
0 Z hundred dollars IS 100)or les,.)
U O 1 certify that in the perl'oricame,of tie work fur which this per DTV. MECHA ICAL PERMIT FEE FEE SUMMARY
LL H mit is issued, I shall not employ any person in any manner so as m
Ow become subject to the Workers'Compensation Laws of California. BUILDING
IS.
Date Applicant ALTER OR ADD TO MECH500
>- 0NOTICE TO APPLICANT': If,after making this Certificate of I!x-
. .
Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must Ibrthwith 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 10.000GEM.) 6.00 SEISMIC FEE
I hereby affirm that there is a conslnrotion lending agency for EXHAUST HOOD(WITH DUCT) 5.00
Ole 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 r in
HEATfNG UNIT 100,000 B.T.U.)9.50
' Po -, 4 ��— ELECTRIC
Lender's Address
I certify that I have read this application aild.Ral 1ha1Wu above VENTILATION FAN (SINGLE) 4.00
. in lbrnetion is-correct. I agree to comply with all city and county PLUMBING
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 enter upon the )
above-mentioned property for inspection purposes. BOILER-COMPIOver 100,0008TUl SEE FEE SCH. MECHANICAL
(We) agree Or 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 against Said City in consequence of lire
grant Of this permit MECH.CONT, LIC.NO. MECH.
TOTAL TOTAL
Sign are III X0pd`c,rit1C`.Rl,!lR=,
INSPECTOR COPY