C8336 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON - PERMIT NUMBER
BADDRESS UILDING APPLICATION & PERMIT 8r BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
336
"21637 OwNE 637 MOSARIO DR, PLAN CHECK VALIDATION
NAME DTV. ELECTRIC PERMIT FEE `
PHON
NAME DREW N �sr do,IMt . UTLETS-SWITCHES-RECEP 10.00/1.00
ay0a- Ie..No LIGHTING FIXTURES 10.00/1.00 S ,
O
ADDRESS PPLIANCES-RESIDENTIAL 4.00
U
PHONE PANELS 10.00 GATE OF APPLICATION
Sj
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
r
4 LIC.No. SIGNS TRANS. 3.00
ADDRESS EN SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
Ilia ii�� zIP EMP.METER OR POLE INS. 20.00
ADDRESS 9�G� / _ MOTORS SEE FEE SCH.
,y SERVICE CHANGE 20.00
0
-00 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a u U I hereby affirm that I am licensed under provisions of Cbapler 9 ISSUANCE DATE
y,Q y (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r o z Professions Code, d m license is in full lure a d of act. f
`z o�, - License Class se iLie.
Nutuber AM d
oz -o
yF w r 51
an Date Contractor
�aa m E BUILDING PERMIT
Ica OWNER-BUILUE:R DIiCL R I
o d INFORMATION
w ; c.N I hereby affirm that I am exempt from lire Contraztor's License
MISC.- REFER TO ORD
LL o j Law for the following reason.(Sec 7031.5.Businessand Professions VALUATION $/FT.
_ PERMIT ISSUANCE .
Code:Any City or county which requiresa permit to construct,alter, 1000
n
IQ ¢ a p improve,demolish,or repair any structure prior to its issuance,also EL EC DNTR. LIC.NO. ELEC.
�: 0 LL requires the applicant for such pernLt to file a signed statement that OTgL ( PERMIT O
1 6 w m he is licensed pursuant to the provisions of the Contractor's License -
H z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofihc - '
.I� a Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE 'I 7
re II o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.'
1, dam by any applicant for a permit subjects the applicant ton civil penalty ALTER-DRAIN IEA.) 5.00
of not more than five hundred dollar,(5500).) I�t
4 ❑ 1,as owner of the property,or my omployces with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
y 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
j Code:The Contractors License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP5.00 .Fr.FLODR AREA TOTAL ACREAGE
( • himself or through his own employees,provided that such improve-
fi
mentsare not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 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 air- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL,WASTE INTER. 30.00 RES IND CON PB Omer
❑ 1,as owner of the properly,am exclusively contracting with ❑ ❑ ❑ ❑
t' l licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
j S t and Professions Code:The Commctor's License Law docs not apply ,.
1-. J to an owner of property who builds or improves thereon,and who LAWN SPR IN KLERS-OVER 5 (EA.) 1.00
b eon tracts for such projects with a eontruetor(o limnscd pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
5� ❑ lam exempt mhder Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00 `
u: rcason
[);it, WATER SYSTEM ' 5.00
, ACC.DATE ACC.FILE No.
') WORKIRS COMPENSATION DICLARAI ION
WATER TREATING EQUIP. 5.00
3 1 luneby affirm that I have a4ift et ol lon,.H lo sell,...ure, -
or U'1'wa t I WDrh'L''/C66mp7r�se Ni�o��nyy�Insludll or a certified ZONING ENG.SITE NO.
� C1 crO copy is hereby furnis d FIRE SPRINK ENERGY TZ4
Z_ 2 ❑ ['ertificd py is Ided with the city in.apechon divi,aon.
MISC. REFER TO ORD.
O.- nppfirant Y ❑ N❑ Y ❑ N❑
~ rn ( PERMIT ISSUANCE 10.00
cc 1 ICP - C '1'F- P p. EIMPTIFROM WORKERS' PERMIT ZONE AL.U.c.
LL I ) COMPENSATION INSNSURANCIiP .CONTR. LIC.NO. PLG, ❑ ❑ ❑ ❑
d O ('This�mction need not he completed if the permit is for one TOTAL Y N V N
Z) Z hundred dollnrs(S 100)or less.)
U O 1 eertify,that in the performance of the work for whlc�l,this.per` DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mil is Issued,I shall not employ any person in un Y'manrTer o $rlo -
U become subject to the Workers'Compensation Laws d`.CaliNrma.
1� O a Daae ' Applicant t / BUILDING h/J
t ALTER OR ADD TO MECH. 5.00
�., } to NOTICE TO'APPLIC'ANU: If,after making this Ccrtilicutc of Fx-
F Z mnption,you should become subject to lire Workers'Compensation APPLIANCE 5.00 PLAN CHECK
phs,sians of the Labor Cade, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00 FEE /
CONSTRUCTION LENDINGAGENCy AIR HANDLING UNIT(OVER IO,000QF.M.) 6.00 SEISMIC FEE �l
L} I Lhereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 /T the performancclof the work for which this permit is issued fSec. MICROFILM
3097,'0v.0). I HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name 1
Lender's Addles. HEATI NG UN IT(OV E R 100,000 B.T.U.)9.50 ELECTRIC 00
' I certify that I have read this application and staff a that the above VENTILATION FAN (SINGLE) 4.00
• information isl correct.1 agree to comply with all city and county PLUMBING pp
ordinances and stale laws relating to building ConstmcIion. and BOILER-COMPI3 H.P.or100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)-S EE FEE SCH. MECHANICAL (�(]
abovcmentioned properly for inspection purpoms.
(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 this permit. MECH.CONT. LIC.NO. MECH.
A57do f'
101- .' TOTAL / TOTAL 3 /
ant/ o
�\ - INSPECTOR COPY