8341 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
x no'ieeN APPLICATION& PERMIT ^ n
�O BUILDING - ELECTRICAL-PLUMBING-MECHANICAL S
O NER'sy��(� PLANCHECK VALIDATION
•7°
NAME
ry�do���„ L QTY. ELECTRIC PERMIT FEE
PHONE
CONTRACTORS (✓-
NAME UTLETS-SWITCHES-RECEP 10.00/1.00 ��38
LIC.NO, LIGHTING FIXTURES 10.00/1.00 �. ! ��
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00 •S.S
AODR Eas
6EC
'.ONE (J PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 ?LAN CHECK FEE P.C.No.
OR
ENGINEER
ON uc.No. SIGNS TRANS. 3.00
AARCH.OR DDRESS ENG. SPECIAL CIRCUIT 5,00 F, PERMIT VALIDATION '
ZIP EMP. METER OR POLE INS. 20.00 /
AMOTORS SEE FEE SCH.
ADDDRESSDRESS
SERVICE CHANGE 20.00
o¢i
Foo LICENSED CONTRACTORS DbCLARA ON TEMP.POLE 30.00
u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
Hzsw (commencing with Section 7000)of Division 3 of the Rusiness and
¢ BLDG. ELECT. I PLG. MECH.
H N Professions Coda,and ivy license is N full force Z.Ce A=- ❑ ❑ ❑ ❑
Z i h o License Class��Lic.Crumb,, 49 ontractor H Date__�/„�-�.__L_Conlmctor
¢ m Y -<+ �l� O BUILDING PERMIT
¢ rt a OWNRR-BUILUIiR DIiCLA RATION
oaO
X g MISC.- REFER TO ORD
LL INFORMATION ,
' N firm Contractor's hereby afthat 1 aexempt Iron the
�. o j Law for the following reason(Sec.]031.5.Business and Professions PERMIT ISSUANCE 10.00 vALUAnON S/FT.
E Code:Any city or county which requires a permit to Construct,alter, ea.
R ¢ Q p improve,denwlish,or repair any structure,prior In its issuance,also ELEC.CONTR, LIC.NO. ELEC. -` /r �0
a wo u requires the applicant for such Perto file a signed slatcnt.nt that TOTAL PERMIT TO
is he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe
¢ Business and Professions Code)or that he is...input therefrom and QTY. PLUMBING PERMIT FEE •D'Jy �Z U^/
¢ r o the basis for the alleged exemption.Any violation ofSection 7031.5 STORIES TYPE CONSTR.
dam - by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.15.00
of not more than five hundred dollars(5500).):
f ❑ I,as owner of the property,or myemployees with wages as BACK F LOW PR OTEC'F�DEV ICE 4.00 OCC:GROUP REB.UNITS
sole compenmtion,will do the work,and the e'tnlcuoc snot
intended or offered for sale (Sec 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law docs not apply to an owner of -
q, properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTAL ACREAGE
• -
*himself or through his own employees.Provided that such improve-
mints am not intended or offered for sale.If.however,lire building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold,within one year of completion, - .the owner- GAS EASYSTEM-OV ER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or ire BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER.. 30.00 RES IND CON PB Omer
❑ I,as owner of the property,um exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct 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
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contract.,',License Law. TRACT NO. PARCEL N0. ♦'
❑ Iam exempt under Sec.-,B&P,C,for this WATER HEATER W/VENT 6.00 -
reason
Owner Ua]c WATER SYSTEM�� 5.00
ACC.GATE ACF FILE NO.
_ WORK ERS'COMPENSAI ION DECLARATION WATER TREATING EQUIP. 5.00
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 there.((Sec.3800.Lab.C.l. l Policy �� fli 4�^t
Q ❑ CerrmshclCl I�f `1i1 L��1}IS'1nvrby fu FIRE SPRINK ENERGY T 24
Z Z ❑ Certified LoZigrs filed with the city inspection division. iA�
O� Applicuv 7� �-�gyb�'v MISC.- 1- REFER TO ORD. v❑ N❑ Y ❑ N❑
~ va PERMIT ISSUANCE 10.00
' - CERTIFICATE OP EXF-AIPTION FROM WORKERS' FLOOD ZONE A.L.U.C.
L COMPENSATION INSURANCE PLG.CONTR. UC.NO. PLG.
d O (This Action need not be completed if the permit is for one TOTAL Y E] N❑ Y ii .1i::IZ hundred dollars 61001 or less.) I
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
L U mit is issued,I shall not employ any person in any manner,so as to
become subject to the Workers'Conpersut ion Laws of California.
z U a Date Applicant - ALTER OR ADD TO MECH. U9 ��.- BUILDING S-J
} to NOTICE TO APPLICANT: If,aflcr making this Certificate of Ex-
Z_ emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of tire Labor Code, you must forthwith comply with FEE
` U such provisioris or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1O=C.F.NL) 4.00
CONSTRUCTION L17NDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE .203
1 hereby affirm that there is a construction lending agency for ,EXHAUST HOOD(WITH DUCT) 5.00
ilia performance of the work fnr which this permit is issued(Sec MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 _
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and county PLUMBING ,
ordinances and state laws relating to building construction, and BOILER-OOMP(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 inspeclion purposes. BOILER-COMP (Over 100,000 BTU(SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep hartnle" the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 1 CONST.TAX
may in any way accrue against said City in consequence of the A-00
granting Of this'permiL MECH.CONT., UG NO. MECH.
TOTAL S
tmatureo I -2 °i' TOTAL 3 3
6 p icon(/ mmetor Dale •��
INSPECTOR COPY