C8498 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BILLING APPLICATION & PERMIT
iL ADDRESS 223V1 SA,V77) OAUu4i4
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL ✓ 8498
OWNER'S PLAN CHECK VALIDATION
.�
NAME 11/� (Y01?) QTY. ELECTRIC PERMIT FEE
AGOSrwo gu221o. PHONE
CONTRACTOR'S
NAME Iy0$l UTLETS-SWITCHES-RECEP 10.00/1.00
/ WD�P TCL r LIC.NO.'733- LIGHTING FIXTURES 10.00/1.00
ADDRESS
DRESCTora
DAPPLIANCES-RESIDENTIAL 4.00
CONTRA
PHONE PANELS 10.00 DATE OF APPLICATION
ogcHrtecr PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER TO f'�'v,l pA UI_R _
01 SIGNS TRANS. 3.00
ARCH, ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
s9y CNRNnIN4 Ari.. I
-- ziP EMP.METER OR POLE INS. 20.00
CA
ADDRESS R
ASS ?2.U3 DeAda,a C1ac1.0 IMOTORS SEE FEE SCH. PAID ki
SERVICE CHANGE 20.00
woo LICENSED CONTRACIORS DECLARATION TEMP.POLE 30.00 JUL 12 1985 1
u I hereby affirm That I am licensed under provision of Chapter 9 ISSUANCE DATE
yam (connmencing with Seclien 7000)of Division 3 of the Business and BLD yE�CL` yyyyG. MECH.
F N z Professions Code,and my license is in full force and effect. ❑ pCr rrn0 ❑
z 0 m - License Class Lie.Number u•
no F eu eu Dale Contractor
RE m E BUILDING PERMIT
S, re re U OWNER-BUILDER DECLARATION INFORMATION
w 3 u v, I hereby affirm that I are exempt frons the Contractor's License MISC.- REFER TO ORD
VALUATION
F I� 0< Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 1000 $/FT.
Code:Any city or county which requires a permit to construct,after,
re Q Q 0- Improve,demolish,or repair any structure,prior t0 its ISSmIloc,also ELEC.CONTE. LIC.NO. ELEC. ,
uOo IL requires the applicant for such permit to file a signed statement that TOTAL ER IT TO
,.� w m m he is licensed pursuant to the provisions of the Contractor's License
H z ¢ Law(Chapler9(cenmmlencingwilh Seclion7000)of Division3of(IIc
Business and Professions Code)or UwI he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r athe basis for the alleged exemption.Any violation of Secliun 7031.5 STORIES TYPE CONSTR.
i ;m by any applicant I' r mit oa persubjects th applicant too civil penally _
ofnol more than five hundred dullms(5500).1: ALTER-DRAIN -WATER (EA.) 5.00 �,
❑ I,as owner of the property,or my employees with wages us BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and Ilse£Uncture is nal OCC.GROUP RES.UNITS '
intended or offered for sale (Ser. 7044, Business and I'rufessiuns DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code: The Contractor's Liccrw Law docs nal apply to an owner of 1105/
properly who builds or iniproves thereon,and who does Stich work FIXTURES-PER TRAP 5.00 50.FT,FLOOR AREA TOTAL ACREAGE
• himself or through his own employees:Provided that such in'
prove-
nt
prove-
cm,are not intended or offered for sale.If,however,the building GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement Is sold within one year of completion,lire owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the buNen of proving that Ie did not huild or im- LDING u5E
r F prove for purpose of sale.). R IND CON PB Other
m I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 El El El Ellicihset contractor to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor'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
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
' the Contractor's License Law. TRACT NO. PARCEL NO.
❑nlmmexemptunder See. .B.&P.C.for this WATER HEATER W/VENT 6.00
re -�
Owner Date�yZi a Z. WATERSYSTEM 5.00
/ ACC.OATE ACC.FILE NO.
W' KE RS'COMPHNSA TION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent In self-insure. ZONING ENG.SITE N0.
or a Certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800.Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished.
FIRE SPRINK ENERGY T-24
0
Z Ell Certified Copy is filed with the city inspection divisioli. MISC.- REFER TO ORD.
O Applicanty� ry� ; [:] NJ[]
~ N - PERMIT ISSUANCE 10.00
LU CIIRTI FICA MPENP A% ION
R051 WORKERS' FLOOD ZONE A.Lu.C.
CL COd not be completed
INSU if the PLG.CONTE. LIC.NO. PLGCL . Y❑ N❑ Y❑ N
Z (This section $10J not be complclN if the permit is 1'or one TOTAL
hundred dollars(5100)or less.)
C..) O I certify that in line performance of the work for which this per OTY. MECHANICAL PERMIT FEE FEE SUMMARY
,. LL f- slit is issued,I shall not employ any person in any planner so as to
O w become subject 10 tine Workers Cm
opensation Laws of Calilomia.
CIL Date Applicant BUILDING
} N NOTICE TO APPLICANT: If,after making(his Ccf(ificalc of Ex- 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
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE J�
. ::11P 1 hereby affirm that (here 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.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's NameHEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
1 certify that I have read this application modstale(hat the above VENTILATION_ FAN (SINGLE) 4.00
• information i correct. 1 agree to comply with all city and County PLUMBING
ordinances and slat, laws relating to building construction, wId BOILER-CO MPI3H.P.or100,000B.T.U.) 6.00
hereby authorize representatives of this city (o cn(vr upon the BOILER-COMP (Over 100000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree to Save, indemnify and keep harmless lire City of MISC.- REFER TO ORD. CONST.TAX ,�j
a Cupertino against liabilities,judgnmmts, costs and expenses which PERMIT ISSUANCE 10.00 (/v
may in any way accrue against said City in conse(plence of the �r
granting of this permit, MECH.CONT. LIC.NO. - MECH.
- TOTAL TOTAL
R
Sig re pplicunl/Cont or ale
INSPECTOR COPY "