8149 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING ^ APPLICATION & PERMIT ///111
X ADOREss4Z�S ./�C�,,y,��7- /l O• 8149 Qg
-___Til / BUILDING - ELECTRICAL-PLUMBING-MECHANICAL ilTl,
OwNEA 9 PLAN CHECK VALIDATION
�r NAME OTY. ELECTRIC PERMIT FEE
PRONE
caNTRacTORs /�/� OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME G45 TELL/NO Ob E-/4I L
/��,No, LIGHTING FIXTURES 10.00/1.00
r, N RACTOR'E SAN /eVNU APPLIANCES-RESIDENTIAL 4.00 --
AooREss p+�
PHONE VIS-8 7.4-111 PANELS 10.00 DATE OF APPLICATION
AR HI E PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00 ..
ENGINEER
' Sec,NO SIGNS TRANS. 3.00 '
ARCH.OR ENG. SPECIALCIRCUIT 5.00 n'.+ PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ADDRESSTs MOTORS SEE FEE SCH. q
SERVICE CHANGE 20.00 3//
w o o LICIiNSE D CON TRACTORS DIiCLARA'f]ON TEMP.POLE 30.00
< U I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
w ¢ N (commencing with Section 7000)of Division 3 of the Bestrews anJ BLDG. ELECT. PIG. MECH.
H D z Professions Code,and my license is in full force and effect. ❑ ❑ ❑ ❑
zO License Clazs / - Lic.Number
Q w7 Date Contractor
BUILDING PERMIT
Or ¢ w st OWNER-BUILDER DECLARAI ON
o s MISC.- REFER TO ORD INFORMATION
F
3 U. w 1 hereby affirm that I am exempt from the Contractor's License VALUATION S/FT.
H u D a Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
,�✓� � Code Anycity orcounly which requires a permit to construct.alter,'
¢ ¢Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
as D ¢ requires the applicant for such permit to file a signed statement that TOTAL a�a S� PERMIT TO
whe is licensed pursuant to the provisions of the Contractors License
H z i
Law(Chapter 9(cummencing with Section 7000)of Division 3 of the
e Business and Professions Code)or that he is exempt therefrom antiQTY. PLUMBING PERMIT FEE 1
¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant ton civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500)J:
/ ❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the Structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's L'icensu Law doe not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SQ FT.FLOOR AREA TOTAL ACREAGE
himscllor through his own employees,provided that such intprow-
mentsarenotintended or offered for sale.If,however,the building GAS-EA.SYSTEM-l1NC-40UTLETS 6.00
or improvement is sold within one year of completion,the owner- (,GAS-EASYSTEM-OVER 4(EA) 200 BUILDING USE
builder will have the burden of promng that he did not build or ion- . . .
RES IND CON PB Omer
1,:iso
prove of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ El ❑ El El
owner
of the property,am exclusively contending with
licensed
:is ocaions tractors to The
Ole project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law doesmoan not apply
to tr owner of property who builds tr improvesensed n.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractor)sl licensed pursuant m SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License law. TRACT N0. PARCEL NO.
❑ loon exempt under Sec. ,B.&P.C.for Oris WATER HEATER W/VENT 6.00
magma
Owncr Date WATER SYSTEM• 5.00 ACC.DATE ACC,FILE NO.
WORK GRS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
I hereby affirm that I have a certificate of consent l0 self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec 3800,Lab CA
Policy N'o. Company�'�y:�,�
0 ❑ Cerl1 Sed L p is hereby fumis�•hit(.N' FIRE SPRINK ENERGY T 24
Z Z O CenifieA copy Gy ti4d -Ovtl� p inspection division. MISC.- REFER TO ORD.
OT Applicant �/!/) /( 1 Y ❑ N❑ Y ❑ N❑
cc CER'n ITCATIi OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOOZONE A.L.U.C.
LU > COSiPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL (This Section need not be completed if the permit is for one TOTAL Y❑ N❑ V ❑ N❑
Z) Z hundred dollars IS 100)or leu.)
- U O 1 certify that in the pertormance.of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is Lsowd,I shall not employ any person in any mennerso as to
U. become subject to the Workers'Compensation Laws of California.
U w, Date Applicant BUILDING
} rail NOTICE TO APPLICANT: If,after making this Certificate of fix- ALTER OR ADD TO MECH, 5.00
♦- Z emption,you should become 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
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNITIOVER 10,000C.F.M.) 6.00 - SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
_information is correct. 1 agree to comply with all city and county PLUMBING
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
above-mentioned property for inspection purposes. BOILER-COMP(Over 100,000 BTU(SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. _-
Cupertino again, liabilities,judge rets, costs and expenses which CONST.TAX
may in any way ' gar sal 21l'y`in consequence of the PERMIT ISSUANCE 10.00
granting of this p LL MECH.CONT. LIC.NO. MECH.
el
TOTAL TOTAL
amre o App U e
INSPECTOR COPY