C8459 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS ;,7 IG _
FG,'Ioe BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
' 8459
RS
NAME
' DTV. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION
. C i� PHONE C-�4 _
CONTRACTOR'S
rvamEOUTLETS-SWITCHES-RECEP 10.00/7.00
! TOR'S/ff r• n r LIC.NO H7rl�if LIGHTING FIXTURES 10.00/1.00
CONTRACTOR
ADDRESS PPLIANCES-RESIDENTIAL 4.00
/ FPHONE Cjf( �G] PANELS 10.00
GATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.NO. 'SIGNS TRANS. 3.00
ARCH OR ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
-�..,
AZIP EMP.METER OR POLE INS. 20.00
ADDRDRLES
•.. MOTORS SEE FEE SCH.
LES
t .1 SERVICE CHANGE 20.00 //
r 1 _.3A IIt fat. A 7/`/e/e'S-
0 f s ! I 'I TEMP.POLE 30.00
Foo LICENSED CON'I'RACTORB DGC),ARATIO7� ,.^ J
a u hereby allium tint um licensed under//Orovisir'i of Cha v r.f! 4..I ISSUANCE DATE
ow (commencing Willi Section 7000)of Division 3 orthe Business and BLDG. ELECT. PLG. MECH.
z Professions Codc,and try license is in full force and effect.
zo D w - License Class RT Lu.Number 11 f2?
Dale Contractor !l� v ❑ ❑
F v,- - . r'"P/. 1 n
r
a w ¢ O NCR-BUILDER DECLARATION . j BUILDING PERMIT
A o 0 o INFORMATION
X 3: N 1 hereby a'ollowfOnm that I am exempt from the Contractor's License MISC.- REFER TO ORD
F LLoJ Law for the lingreason.(Sec.7031.5.Bu,mv,,and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city or county which requires a permit to construct,alter,
sa ¢ 2 improve-,hurmlisli,or repair any structure,prior to its issuance,also ELEC.CONTR. LIG rv0. ELEC.
_ -ct I[ Rquires the epplieanl for such permit to file a signed sla4ment that TOTAL PERMIT TO
w m y W is licensed pursuant to lire provisions of the Contractor's License
rz a Law(Chapler 9(commencingwitln Section 7000)of Division 3 ofthe //T
E i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE L/-'T /
r m the basis for the alleged exemption.Any violation of SvcIion703I.5 STORIES TYPE CONSTR,
a3 _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than rive hundred dollars(5500).):
❑ I,as owner at the properly,or my employees with rewages as
not BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their , compensation,will do the work,and the structure is not
intended or offered for sale (Sue. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,CON D. 5.00
Code:The Contractor License Law does not apply to an owner of
property who builds or improves thereon,and who does such work - FIXTURES-PER TRAP 5.00 SD.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,s provided that such im building
mems are not intended or rlrureJ for sale.IC however,the building GAS-EA.SV$TEM-11NC.40UTLETS 6.00
or improvement is will within one year of completion,the owner-
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose ol'sulal' INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB other
❑ 11 as owner of the property,am exclusively contracting with
a ,]Plicensed contractors to he
tile project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL No.
and,, ofussioof Code:upel'hc Contractor's m,nov Law does not apply
fo un ctso.rurfo pi mopeny will)
Willi a ds ractonovecensed n.and who LAWN SPR INKLER$-OVER 5(EA.) 1.00
contracts forsuch projects with a conlrudor(sl licensed pursuant to
the 1ionexe License Sec. SEWER-SANITARY-STORM EA.2001t/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for Ibis WATER HEATER Al 6.00
rL'asDll
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSA'IION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm the I Imve wecrtificate ofconsenl to self-insure.
or a cetlificale of Workers'Compensation insurance.or a certified ZONING ENG.SITE NO.
copy there flSec.��00,Lab.C.l.
Policy No.��_-Mi5mpany
O Q Certified copy is hereby furnislic FIRE SPRINK ENERGY TQA
z Z D Certifiedcopy is fled with thin city inspection division.
F- O Applicadl v J - / MISC.- REFER TO ORD. Y E] N E] Y E] N[3
N CER1'IFI ATHOF EXI:MI1L N FRO' M WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.O.
LU > COMPI>NSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
Z (This section need nut be Completed if the permit is for one TOTAL - Y_E] N Y [:] ❑
N •
hundred dollars(S 100)or less.)
U O I certify that in tine performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner so as to
U U become subject to the Workers'Compensation Laws of California.
OL Date Applicant ALTER OR ADD TO MECH. 500 BUILDING D�
>_ N NO'I'IC17 "FO APPLICAN'C 11,alter making this Certificate of Ex-
.
Z cmption,you should bee onm subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK 3 S^
provisions of the Labor Code, you most forthwith comply with
U such provisions or this pennit shall be deemed revoked AIR HANDLING UNIT(TO 10=CF.M.) 4.00 FEE Al
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 6.00 SEISMIC FEE ISS
1 herehy affirm Ihm dere is a construction lending agency forEXHAUST HOOD (WITH DUCT) 5.00 r
the performance of the work lis which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender;Name
Lenders,Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00 •I-
odonances n correct.I agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building l city an ion, and BOILER-COUP(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.
above-mentioned property for inspection purposes. MECHANICAL
(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 10.00ECH.
CONST.TAX
may .any way accrue against saideCily in consequence of the
.` granliinn of this Perotil �✓ MECH.CONT. LIC.NO. M
i TOTAL TOTAL E�
Slgmeture of Applicant/C- ntrac[or Date 3/r
INSPECTOR COPY