C8504 APPLICANT.TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN`ONLY
BU I LOING PROJECT I DENTIFI NPERMIT NUMBER
X
BUILDING APPLICATION & POIT -
ADDRESS r v
BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
Owry ER'E ( PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
' P in vHONE
Name croRs" UTLETS-SWITCHES-RECEP 10.00/1.00
"V
ADDRESS I UC.NO. LIGHTING FIXTURES ' 10.00/1.00
TEpSffi APPLIANCES-RESIDENTIAL 4.00 '
ADDRESS
PHONE PANELS 10.00 PATE OF APPLICATION
RCHIEr - PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE
OP.C.NO.
OR
NGINEER
Lie
o No. 71
SIGNS TRANS. 3.00
ADDREss ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zIP EMP.METER OR POLE INS: 20.00 n
APPLIOOHCSS
AOOR E$$
ANTS
MOTORS I SEE FEE SCH. W. S
7 SERVICE CHAN E 20.00 > y"
i
re
'02 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00re
a
ta u 1 hereby'affirm thou I am licensed under provisions of Chapter 9 ISSUANCE DATE- y
w Q n (commencing with Section 70001 al'Division 3 of the BusiO¢Ss and BLDG. ELECT. PLG. MECH.
H
is z Professions Code,and my license is in full force and effect ❑ ❑ 1:1 ❑
zOw - License Class Contractor
I•.^/u/
•*O m�, Daley/�[,�Conlmttor
a a J I ITIt'r6 r rL BUILDING PERMIT
a OWNER-BUILDER DECLARATION
-e, o s" MISC.- REFER TO ORD INFORMATION
- w ;LL H I hereby affirm that I am exempt from the Contractor's License -
w VALUATION $/FT.
,_x
u 0 4 Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSU6NCE 10.00 _V
mj Code:Any city or county which requiresa permit to construct,alter,
re , a O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
LL requires the applicant for such permit to file a signed statement that TOTAL '�� PERMIT70
R:
revs is licensed punamnt m the provisions of elm COaftador's License
HZi
Law(Chapter 9(commencingwith Station 7000)ofDivision 3 of the f,TEr7
DTV.
a Business and Professions Code)or that he is exempt therefrom and PLUMBING PERMIT FEE
¢ r m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES YVPE CONSTR.,
by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(55000.):
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 OCG GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 -
Code:The Contractor's License Law does nut apply to an owner of
properly who builds Or Improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
• himself re through his own employees,provided that such improve
hients mself enot intended or employee ffered sa provided
that sthchuildingose. GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion, - . -OVER 4 (EA.) 2.00 the owner- GAS EASYSTEM
builder will have the burden of proving that he did not build or am- BUILDING USE
prove for pulp...f,.k.L INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ I,as owner of the property,am exclusively contracting with El 0 El El 0
licensed contractors to construct 019 project(Sec. 7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL No.
and Professions Code:The Contmcca's'License Law does not apply
{ to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
If contracts lou such projects with a conlructortsy licensed pursuant to
the Contractor's License Law. SEWE R-SANITARY-STO RM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATEfi W/VENT 6_00
reason N [
Owner Y Uam WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
WORK 1:RS'COMPENSA'1'[ON DECLARATION WATER TREATING EQUIP. 5.00
I licamy ultirm that I have a eeruifcate of consent to sell nnurc, ZONING ENG.SITE N0.
.r a caa lcate of Workers'Compensation Insurance,or u certified
copy thereof(Sec.3800,Lab.C.).
t Policy No.- pfpq_Company iu i•99^T - r s^r
O ❑ Celli of•d Copy is hereby(alai hCd. FIRE SPRINK ENERGY T-YO
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. ll��ss
O Applicantp,Zt _ 4A Y❑ N V ❑ No
• CC y PERMIT ISSUANCE 10.00
LU CfSR'1'I FICCO1 P F EXEMPTION ION INS FROM WORKERS' FLOOD ZONE A.L.u.C.
W (.OMPIiNBATION INSURANCE PLG.CONTRA LIC.NO. TOGA y� N� y ❑ N11
CL Z (This Action need not be complemtl if the pC nn it i far one TOTAL
hundred dollars(5100)or less.)
U O I certify that in the performance of the work for which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued.I shall not employ any person in any manner so as to
,- Ow become subject to the Worker% m
Coptnsali n Laws of California.
y Date -Applicant nz91 ALTER OR ADD TO MECH. 5.00 BUILDING USZ
} W NOTICE TO APPLICANT: If,after nr ,i •this Cerlificute of Gx-
N Z cmption,you should become subject In the Workeri Compensation q APPLIANCE 5.00 PLAN CHECK
Provismn, of the Labor Code, you nmst hanhwith comply with '32-
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 FEE .Z
CO.INSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a runstroctum lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Cie,C.) / HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name-
Lender's Address L'I��.t HEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certily that I have read Ibis afflhenlion and state that(he above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING (N
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 BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
'(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 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
r granting of this permit MECH.CONT. LIC.NO. MECH. -
t� OTAL TOTAL j
Signature of ApPir3MlCon�act-4-� Date ` �/ s
INSPECTOR COPY