8434 (2) APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL _POINT PEN ONLY
o
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
ADDRESS APPLICATION & PERMIT ��34
ADDRESS
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BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
i ANE s PLAN CHECK VALIDATION
NAME
- '�(,LpEATi A10Rgf�TNEk$QTV. ELECTRIC PERMIT FEE
PRONE
NAMERAcroRs BJ � l ,+ab scAPE UTLETS-SWITCHES-RECEP 10.00/1.00
uc.NO. ,� 5 LIGHTING FIXTURES 10.00/1.00
' CaNTRACTOR's q {�/- ,I
✓E, APPLIANCES-RESIDENTIAL 4.00
vRONE _ PANELS 10.00 PATE OF APPLICATION
0RcmrEcr r (�4utPPks-NO LY.°?�B37 PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.No.
ENGINEER
LIC,NO SIGNS TRANS. 3.00
ADDRESS emo SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zIP TEMP. METER OR POLE INS. 20.00
APPLICANT'$
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 � � 5'"'�
FO Sir o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a v I hereby affirm that 1 am licensed under provisions of Chapter 9
ISSUANCE DATE
"' (commencing with Section 7000)of Division 3 of the Business anti BLDG. ELECT. PLG- MECH.
z Professions Code,and my license is in full force and effect. ❑ Elp z w o License Class_ n Lia Number
F 11
s, r ar. Date Contractor
a Y BUILDING PERMIT
wa OWNER-BUILDER DECLARATIO
o d 0 INFORMATION
w3 LL 1 hereby affirm that I am exempt from the Contract is License MISC.- REFER TO ORD
u O j Luw for the following reason.(Sec.703 L5,Business and Professions VALUATION $/FT.
r - PERMIT ISSUANCE 10.00
Code.Any city or county which requires e permit to....tr ilL alter,
IS U i- 0 Improve,demolish,Or repair any structure,prior to Its Issuance,also ELEC.CONTR. LIC.NO.
ELEC.
O LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
u w m he is licensed pursuant to the provisions of the Contractors License
HZQLaw(Chapter 9(commencingwith Section 7000)o'Division 3 ofthe
i O Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT :FEE
S H , the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d3 �2 by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.15.0
of not more than five hundred dollars($500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCG GROUP RES.UNITS
their sole compe.sat in n,will do Int work-and the s[ructu re is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND.
Code:The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon,and who does Suds work FIXTURES-PER TRAP 5. SG.FT FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
ments are lint intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.
or improvement is sold within one year of completion,tiro owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have,the burden of proving that he did not build or int- BUILDING USE
prove for propose of sole.). RES IND CON PB One.,
❑..1,as owner of lire property',aln exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
licemcd'contraemrs to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.0 ASSESSORS PARCEL NO.
and Professions Code:The Cont actor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPR INKLERS-OVER 5 (EA.� 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL No.
❑ Iamexemptunder Sea - ,B.&P.C.fnrt[iisunis
on WATER HEATER W/VENT 6.00
Owner Date WATER SS
- YTEM � .S ACG DATE ACC.RLE NO.
WORKF-RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.
I hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec,3800,Lab.C.T
Policy No/
$,�/�C omre y �, // aQ L�
O ❑ CenilF,,pyisherehyfurni1U1 FIRE SPRINK ENERGY T-24
z Z Certified co y is filed with 0 city inspection division
P: O , cant MISC.- REFER TO ORD. Y NE] YE] NE]m `� '- PERMIT ISSUANCE
� CliRII FICCOMPE -REM SU ROM WORKERS' / FLOOD ZONE A.L.U.C.
Q_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
Q_ (This section need not be completed if the permit is for one TOTAL Y❑ IN Y ❑ N❑
Z harried dollars IN 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 U mit is issued,I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} rA NOTICE TO APPLICANT. If,after making this Certificate of Ex-
F Z caption,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
CONST RUC'T'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
I hereby aftina that there is a construction lending agency mr 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
Tender's Name
Lenders Address HEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Icertil'y that l have read this application and state that lhu above VENTILATION FAN (SINGLE) 4.00 1
information is correct. I agree to comply with all city and county PLUMBING //
oninances and state laws relating to building construction. and BOILER-COME(3 H.P.or 100,000 B.T.U.) 6.00 v
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTUI SEE FEE SCH. MECHANICAL
J 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 CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
granting of Ih is permit. - MECH.CONT. LIC.NO. MECH.
roTAL TOTAL /
na ore of scan aractor a e
INSPECTOR COPY