8400 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
1)4 BDILDING APPLICATION & PERMIT
ADDRESS
t a
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 8400
OwNERS I PLAN CHECK VALIDATION
NAME
QTY. ELECTRIC PERMIT FEE
/ \• PHONE
NAIVE oR's' OUTLETS-SWITCHES-.RECEP 10.00/1.00
km/ r u
( c.NO. 32e,;() LIGHTING FIXTURES 10.00/1.00
.o RACTOR'S o�
aooREss PPLIANCES-RESIDENTIAL 4.00 '
9 //
tnll' PANELS 10.00 DATE OF APPLICATION
RRCHI cT r' PANELS (OVER 200 AMP) 20.0Q PLAN CHECK FEE P.C.NO.
O
ENGINEER
uc.NO. SIGNS TRANS. 3.00
ARCH.OR ADDRESS ENG SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP rFEMP.METER OR POLE INS. 20.00
APPLICANTSMOTORS SEE FEE SCH. S
AODRE55
SERVICE CHANGE 20.00
5
, woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
rz w 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
¢ e, (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
,-y i Professions Code,and my license is in full force and effect. ❑ ❑ �\ ❑
License Class Lic.Number
9 m -Dute�Com me"r -
F _ J v
¢ a w OWNER-BUILUEk U[CLARATIO �/ BUILDING PERMIT
1//I'�. INFORMATION
w ;LL vHi I hereby affirm that I am exempt from tire Contractors Licen MISC.- REFER TO ORD
uD J Law for the following rcas.d.(Sec.7031.5.Bosinessand Professions VALUATION $/FT.
H - PERMIT ISSUANCE 10.00
¢ m�+ Code:Any cityor romtywhiny requires ep prior t oconsuancdoer,
'u � ELEC.CONTR. LIG NO.
R ¢ 0 improve,demolish,Or repair any structure,prior to its issuance,also TOTAL LL req is tic ns applicant t t tiro permit t0 file J signed Cont actor's 0t that TOTAL PERMIT TO
R
m ht is licensed pursuant n the provisions of the Contractor's License
H z a Law(Chapter 9(commencing or than ie is exempt
therefrom
om the
and
F 4 D Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ h- o the basis for the alleged permit
subjects
Any violation Df Se coon malty STORIES TYPE CONSTR.
Ate _ by any applicant for apermit suhjccts the applicant Ina civil penalty
ALTER-DRAIN 5.00
of not more than five hundred dollars($500)}.- t'
❑ 1,as owner of the Property,or my employees will, wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP AES.UNITS
sole compensation,will do the work,and the structure is not
intended cr offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
e 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
himselfor through his own employees,provided that such improve-
memsare not intended oroffered for sale If,however,the building GAS-EA.SVSTEM-I1NC.40UTLETS 6.00 cJh,
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.1' 2.00
builder will have the burden of proving that he did not build or ire- BUILDING USE
prove for purpose Of sale.). RES IND CON PB Other
Cl 1, WASTE INTER. 30.00 1:1 ❑ El ❑ El
I,as owner of the property,am exclusively contracting with
licensed contractors to cmos ruet the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:'1'hc Contractor's License Law does not apply
to an owner of property wlm builds or improves themun,and who LAWN SPRINKLERS-OVER 5 IEA.) 00
contracts for such projects with a contractor(s)licensed pursuant to SE ER-SANITARY-STORM EA.200ft/1 .00
the Contractors License law. TR ACT NO, PARCEL NO.
❑ lam exempt under Sea ,0.&ItC.for alts WATER HEATER W/VENT 6.00
Owner
Owner Date WATER SYSTEM 5.00 U ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING'EQUIP. 5.00
I hereby affirm that I have a certificate ofeanst t to self-insure. ZONING
or p certificate of Workers'Compensation Insurance,or a ornified ENG.SITE NO.
/ copy thro of(Sec.3800,Lah.C.),
Policy No,f4 Compalry %
❑ Cerpfhedcopy'ix hereby'(urttished. FIRE SPRINK ENERGY T 24
b"_-z.
❑ Cetificd�iopY ix/Ad it r'Ih' cilY ins'Pcmion Aivisiun.
;.F O -Appli<ad[ < _ w �? MISC.- REFER TO ORD. Y ❑ N❑ Y [:] NE]
:� rn antRev
C,FR IFICAI'E OIs EXEMPTION FROM WORK F:RS' PERMIT ISSUANCE 10.00 B FLOOD ZONE A.L.U.C.
4;j tf1J > COhll'ENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
, -� ,(This section need not he completed if the permit is for one iQ1 TOTAL V N� V NCD
?,et�:Z, Injected dollars IS 100)or less) •- - '
ki,;10;O 1 certify that in the,performance of the work for which this per- FEE SUMMARY
i. 'unit -
}� U 6 issued1 shall not empty any person m any manner so as to QTY. MECHANICAL PERMIT E
sal rl w bL oro object
ct to the Workers'Compensation Laws of California.
T Dal Applicant • BUILDING
NOI1C1: '1 nPPI lows II,an along this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
nI}tllJn,you should become s'ulj t It the Workr: Chhlns:rtlon APPLIANCE - 5.00 PLAN CHECK
yC�1 y L "pn .&I s of the Labor Code, you must forthwith counlily with
ss �Sy11•yb�isions or this permit shall be deemed rL oked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00 FEE
'CONSTRUCTION LENDING ACI AIR HANDLING UNIT(OVER IO,000OF.M.) 6.00 SEISMIC FEE
SZ<: .•t1; ,.y. :}�.I.hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
ahVPmformance of the work for which this permit is issued(Sec. MICROFILM
(3097;Civ.C). HEATING UNIT(TO.100,000 B.T.U.) 8.00
'Lerider's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Afi "°ks''f?n I certify that l leave rad this application and state that the above VENTILATION FAN (SINGLE) 4.00
mfonn,dion is correct I agree to cotoply with all city and county BOILER-COMP„(3 H P or 1M OOB.T.U.) 6.00 PLUMBING /
c 1 hnan�es and stat haws relating 10 building Construction, and
�q s.{F �locreby amhonm representatives of this my to enter upon tire BOILER COMP 10 a I0000&BTUI SEE FEE SCH. MECHANICAL
yf) al ovL mentioned property for inspection purposes
p ={'Eaj1r� •• QVc) agree to save indemnify and keep harml s the City of SC. r- + a/.Ss l' FsF�ER TO ORD.
J " Cupertino against liabilities, judgments, costs and expenseswhtch x r CONST.TAX
mayraany way accrue against said City in consequence,of the ° PERfV-]IT ISSUANCE i x-f f a 1000
y gn ng f this per i[. _ MECH C ip K'a 1'F y' r`4LIC NOw' M11ELH,eS
TOiA4 F
.•� r k ; *� s ;4Yt 'x { s TOTAL
Pr a u o 'PPhcan on for DatJ•s>#]b• fV+{y.>F�� ,���rnd qk i�'`+ =t�r`"x °7 e
4 I�
v k1 a t