Loading...
8173 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY , m BUILDING PROJECT IDENTIFICATION PERMIT NUMBER BUILDING APPLICATION & PERMIT ADDREBS B8173 UILDING-ELECTRICAL-PLUMBING-MECHANICAL NAME PLAN CHECK VALIDATION S�D�K�mE,i/, 738.3•I sg DTV• ELECTRIC PERMIT FEE PHONE NAME A T R OUTLETS-SWITCHES-RECEP 10.00/1.00 S uc.No. L -4-.- !-,2 LIGHTING FIXTURES 10.00/1.00 W NTRACT Ra ` PPLIANCES-RESIDENTIAL 4,00 ru_ AopREss awn Xva4e 7�//p- / PHONE PANELS 10.00 r- t1+ DATE OF APPLICATION 0qc"ITE PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE PC,NO. ENGI ER uc.No. SIGNS TRANS. 3.00 ADDRESS G / / SPECIAL CIRCUIT 5,00 PERMIT VALIDATION _G- EMP.METER OR POLE INS. 20.00 ADDRESSTs MOTORS SEE FEE SCH. •J o-. �, SERVICE CHANGE 20.00 TK�� X LICENSED CONTRACTORS DELLA RA' ON TEMP.POLE 30.00 VVV wo Ic u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE w az N (commencing with Section 7000)of Division 3 of the Business and BLD ELECT, PLC. MECH. H Z Professions Code nA my license iz in full force u d elleet. z o m — Licenre Class�� Lia Number yy��JJ�� 4 y t La w Pale��'r(p���Contractor jilt; y a m E -+ ,t BUILDING PERMIT ¢.Q w a OWNER-BUILDER am I - se a o erenn Contractor's INFORMATION ; y I hereby affirm that I am exempt from the C ' License MISC.- REFER TO ORD cal LLoa Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE J0.W OV VALUATION SIFT. 0 Code:Anycity orcounly whichrequiresapermit to construct,alter. - Y p o p' y 'or to Its ISSuance,also ELEC.CONTR, LIC.NO. Q re ¢Q improve,demolish, r repair an structure,prior ELEC. O , requires the applicant for such permit to file a signed statement that TOTAL. 7 PERMI TO E $ he is licensed pursuant to the provisions of the Contractor License l H z a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe 4 o Business and Professions Code)or that he is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 DTV. PLUMBING PERMIT FEE STORIES TYPE CONSTR. a3 by any applicant for a pemhit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00 elect more than five hundred dollars(8500).): —��.�� ❑ 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECTDEVICE 400 OCC.GROUP RES.UNITS their sole compensation,will do the work,and the structure is not . . - intended or offered for sale ISec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 5.00 Me:The Contractors License Law does not apply to an owner of properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP S:OO SO.FT.FLOOR AREA TOTAL ACREAGE. • himself or through his own employees,sale.provided leve such improve- menlsarenotintendcdoroemployees, roi,however,ded that ebuilding GAS-EA.SYSTEM-11NC.40UTLETS 6.00 VQ �y� or improvement Is sold within one year of completion,the owner- ' GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 OD builder will have the burden 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 4 ❑ ❑ ❑ ❑ . licensed contractors to con,truct the project(Sec. 7044,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 ?C,\' � (� contracts for such projects with a commetotio licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10A9 a 3 O the Contractor's License Law, 4 TRACT NO. PARCEL NO. na❑alum exempt under Sec. ,B.&Y.C.for this WATER HEATER W/VENT 6, up' Owner Dare WATER SYSTEM -5-OG 5e 41- ACC.DATE ACC.FILE NO. WORK ERS'COM TENSA'(ION DECLARATION WATER TREATING EQUIP. 5.00 1 hereby affirm that 1 have a certificate of consent ID self-insure. or a certificate of Workers Compensation Insurance,or S certified ZONING ENG.SITE NO. mpg thereof(Sec.3800,Lab.CJv�- 'tl ' I'olicY No. Company qd.�s� Q- Q ❑ Certified copy is hereby famishe —" , FIRE SPRINK -.•ENERGY T 24 P: L:) O / ❑ Certified cods filed with the city ins eti divi' n. MISC- REFER TO ORD. y N v N Applicant ❑ ❑ ❑ ❑ - � ���T[W PERMIT ISSUANCE 1A00 ,t OV. FLOOD ZONE AL.UL. rn CER'rl FICA'I'E OF EXEMPTION FROM Wr LU COMPIiNSATION INSURANCIi PLG.CONTR. LIC.NO. PLG. \ CL::I 0 IT actino need not be completed if the permit is for he TOTAL 90 .hl Y❑ N❑ Y ❑ N© hundred dollars IS 100)or lest) 0 1 certify that in the pcd'onnunce of the work for which this per OTY. MECHANICAL PERMIT FEE FEE SUMMARY LL F- mit is issued,I shall not employ any persomin any neanner or as to OW become subject to tireWorkers'Compensar ion Laws of California. C. [)arc Applicant BUILDING L } N NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00 / S F 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 LENDING AGENCY AIR HANDLING UNIT(OVER 10,000OF.M.) 6.00 e, SEISMIC F4 EE 1 hereby affirm that there is a consvuction lending'agency for EXHAUST HOOD (WITH DUCT) ' 5.00 the performance of the work for which t permit is issued(Sec. MICROFILM 3097,Civ.C.). �^ HEATING UNIT(TO 100,000 B.T.U.) 8.00 W LenJer's Name HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC �(0 Lender's Address 1 certify that I have read thisapplication an state th �e a VENTILATION FAN (SINGLE) 4.00 ,F t/L Q W • information is correct. 1 agree ro comply wl h all city and county BOILER H.P.or t00,0008.T.U.) 6.00 PLUMBING / ordinances and nate laws relating to building construction, and hereby authorize representatives of this city to enter upon the BOILER-COMPIOver 100,000 BTU)SEE FEE SCH. MECHANICAL a/a CI-6 above-mentioned property for inspection purposes. l (We) agree to save, indenrniiy and keep harmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs andexpenses which PERMIT ISSUANCE 10.00 ,/U CONST.TAX C may in any way accrue a•ainSt said City in coil qucn ce of the �Q r grodingofthis permit MECH.CONT. LIC.NO. MECH. _ ' 1 TOTAL a (o • TOTAL f'L,«r Sgnaure ol- pplant/Contract Uatc INSPECTOR COPY '