8322 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATION
PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
Z BUILDING- ELECTRICAL-PLUMBING-MECHANICAL 8322
OWNER uRIO ( PLAN CHECK VALIDATION
NAN 4rG PRON _ CITY• ELECTRIC PERMIT FEE
NOMERAc*ons � UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No.,;/yS/�7� LIGHTING FIXTURES 10.00/1.00
TRA Ton's PPLIANCES-RESIDENTIAL 4.00
AD /RE55 �J/�� / �
(. g, s , �>•{.� PRONE 00 -C/ 7, PANELS 10,00 DATE OF APPLICATION
ARRLHITEQ PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
NGINEER
_ uc.No. � SIGNS TRANS. 3.00
ARo Ess ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
AS
PPLICAMOTORS SEE FEE SCH. T V J
ADDRESS
SERVICE CHANGE !20.00
w o 0 LICENSED CON FRACTORS DECLARATION TEMP.POLE •30.00 /�J/p�i-
aZ W I hereby affirm that I um licensed under provisions of Chapter 1 ISSUANCE DATED
(commencing with Section 7000)of Division 3 of the Business and
in¢ ,A,t g BLDG. ELECT. PLG. MECH.
H w Z Professions Co my license is in full fD and of ecL,
z O m - License Class Lic.Number ❑
,Z
t Date Contractor
c ¢
OWNER-Bill LDER DECLARATION BUILDING PERMIT
s o a u INFORMATION
w LL I hcrehy uffinn that I am exempt from the Can tractor',License MISC.- REFER TO ORD
.. o j Law far the following reason.(Sec 703 L5.Business and Professions pERM1T ISSUANCE 10.00 VALUATION $/FT.
Code:Any city or county which requiresa permit toconslruct.alter,
au Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC.
i w m pursuant M requires tire applicant for such permit to file a signed statement that TOTAL PERMIT TO
he is licensed puuant to the provisions of the Contractor's License
rii Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe 04
¢ Business and 1'rofassions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
K F ce the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ; e0 of not more applicant fora Penni! dollbots S500p.he licunt toaeivilpenally ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500)J: '
❑ 1,as'owner of the property.Or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.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 not apply to an owner of
properly 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-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or in, GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose ofsale.).theJ. RES IND CON PB Other
❑ as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00
licensed
contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions property
The Contractor's Licanse Law doesnotapply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts I'or such projects with a eontmctons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
re❑Rlum exempt under Sec. ,B.&P:C.for this WATER HEATER W/VENT 6.00 L
Owner Dale WATER SYSTEM S.00 ACC.DATE ACG FILE NO.
'W OBKERS'COMPENSA1TON DECLARATION WATER TREATING EQUIP. 5.00 "
1 hereby uffinn that 1 have a certificate of ennsont to self-insure ZONING
or a certificate of Workers'Compensation Insurance,oqa �ertified ENO.SITE NO.
co th I in. 800,-L�b.C.l.
P iq{i
Po VON'
0 any
O e m cpyisherebyfui FIRE SPRINK ENERGY T24
Z 2 O Hifred copy is filed with the city inspection division.
O App of MISC.- REFER TO ORD. Y El NE] Y ❑ NE]
~ w rPERMIT ISSUANCE 10
- CERTIFICATE OP EXEMPTION PROM WORKERS' FLOOD ZONE A.L.U.C.
W p' COMPFNSA9'ION INSURANCE PLG.CONTR. LIC.NO, PLG. Y� N� V� N�
Z t1'his'Section need Bol be completed if the permit is for one TOTAL
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mil_is issued,I shall not employ any person in any manner so as to
O U become subject to the Workers'Compensation Laws of California.
p- 'Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} rA NO'f ICE 'I'O APPLICANT'. It, he,making this Certificate of Ex-
F_ Z_ ' eruption,you should beconne 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 10,0000EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the perhornwnce of the work for which this permit is issued(Sec. - MICROFILM
3097,Civ.C.), HEATING UNIT(TO 100,000 B.T.U) 8.00
Lender's Name H EATING UNIT(OV ER 100,000 B.T.U.)9.50
Lender's NAddreo...c ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
. ®
information n correct, 1 s rel to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING � (f
ordinances and state laws relating to building Construction, and rt,
hereby authorize representatives ol' this city to enter upon the BOILER-COMP (Over 100,000BTUISEE FEESCH. MECHANICAL
ubuve-mentioned property for inspection puryoses.
(WC)v gree to save, indemnity and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which Y CONST.TAX •J i+'
may in a y way accrue against said City in consequence of the PERMIT ISSUANCE 10._00 '.
grunting o lh permit. ''''1111 y.� -
/P MECH.CONT. LIQ NO. MECH. 1
/I TOTAL % TOTAL
Signatory of A pplicam/Cbnlrbao -
'
/ INSPECTOR COPY r