C8387 e 'APPL IeANT TO FILL IN INFORM4b(SNWITHIN RED LINES - USE BALL POINT PEN ONLY
+�J 13 LD1 NG PROJECT IDENTIFICATION PERMIT NUMBER
/ e BUILDING. APPLICATION & PERMIT `I
i �}; ADDRESS 1 (� /\/1/�E� t
i4!y' 371 ��r OI I,�c lx.��� U hr'`V F� 1( t UILDING-ELECTRICAL-PLUMBING-MECHANICAL py83y8 li(
~ NAME S I5�1 ✓�U PLAN CHECK VALIDATION
OTY. ELECTRIC PERMIT FEE
PHONE
NAME 'COWS
UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO, LIGHTING FIXTURES 10.00/1.00
f-ONTRACTOH'S
ADDRESS APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
on
(��O PANELS (OVER 200 AMP) 20.00
ENGINEER D ��(( r l:!
uc,Na, SIGNS TRANS. 3.00
moo eSENG. n SPECIALCIRCUIT 5.00 PERMIT VALIDATION
l7 S Ive2a�o Afj, •SJl e- 7 .
1 ZIP d EMP. METER OR POLE INS. 20.00 n ��
ADDRESS rs / I MOTORS SEE FEE SCH.
ADDRESS I
9fC1 ,,, _1 IJ -._t SERVICE CHANGE 20.00
° 0 TEMP.POLE 30.00
r o O LlfliNS1iD CONTRACTORS DECLARATION 3/
a u I hereby al ire that I an licensed under provisions of Chapter 9 ISSUANCE DATE
I" (commencing with Section 7000)of Division 3 of the Business and
D i Professions Code,and my license is in full font,and effect. BLD ELECT. PLG. MECH.
p0 a C License Class Lie.Number
T r EDale Contractor
¢ y '•
° w ¢ OWNI!R-BUI LD 17 1)EC LA RATION BUILDING PERMIT
A °a " MISC.- REFER TO ORD INFORMATION
w 3 F I hereby allinn that I am exempt flan the Conlractoi x Liccnsc
H u o a Low for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE10.00 VALUATION $/FT.
Code:Any city or county which requiresa permit toconstruct,alter,
IF tu Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE, LIC.NO. ELEC.
°¢ requires the applicant for such permit to file a signed statement that TOTAL
u w m m he is licensed pursuaninl to the provisions of the Contractor's License PERMIT TO
Fz>
Law(Chapter 9(commencing wit Section 7000)o'Division 3 of the /J,+� �D /
a Business and Professions Code)or that he is exmnpt therefrom and QTY. PLUMBING PERMIT FEE 1172 ,v
the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a. 5,: by any applicant for a permit subjects the applicant tO a civil penally ALTER-DRAIN -WATER (EA.) 5.00
•.
of not more than five hundred dollars(55001.):
❑ 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,AR EA,CON D. 5.00
Code:'Che Contradculs'License Law does not apply to an owner of
property who bullas Or improves thereon,and who dols such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himselLor through his own employees,provided that such improve-
ments ani`not intended or offered for sale.if.however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owncr-
builder will have the burden of proving that he did not build ori t. GAS-EA.SV STEM-OVER 4 (EA.) 2.00 BUILDING ISE
prove for purpose aside.). RES. IND N PB Other
rk1 l;•as owner of the properly,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 O
licensed contractors to censtrucl the project(Sec. 7044,Busmesx LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSOR PARCEL NO.
and Profession'Code"fire 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 contractorts)licensed pursuant to
the Contractor,License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
I m exempt under Sec. B.&P.C.for Otis
reas❑on WATER HEATER W/VENT 6.00
/11 0-11 WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
L x
WO iKIi Rs t' MPIiNSATION UI'CLA ATION WATER TREATING EQUIP. 5.00
I hereby ate of Thal I have a certificate of comment or aceinsure.
or a certificate le of Workers'Compensation Insurance,or a certified ZONING ENG.SITE N0.
copy thereof(Sec.3800, ).
Policy Na Company
O ❑ Certified copy is hereby furnished, FIRE SPANK ENERGY L}<
Z 0 ❑ Certified copy is filed with the city inspection division. MISC.-�- REFER TO ORD. Y ❑ N� Y ❑ N[3
Applicant '
~ ON PERMIT ISSUANCE 10.00
Lu CIi R'I'I FICATE E EXEMPTION COMPENSATION
ION FRO61 WORKERS' FLOOD ZONE A.L.U.C.
W > COAIPCNSATION INSURANCIi PLG.CONTE. LIQ NO. PLG.
CL Z (This section need not be completed if file permit is for one TOTAL Y❑ IN[J V❑ NFJ
hundred dollar,IS 100)or less.)
U O • I certify that in the performance of life work for which this Per- QTY. MECHANICAL PERMIT FEE
H mil is issued,1 zhi ll nor an to an rson in an manner so os to FEE SUMMARY
LL p y' pea l
Ow becomesubject to the Workup'Compensation Lawsuf California.B. Date Applicant BUILDING 2
>_ GO NOTICE '1'0 APPLICANT': If,.tier making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00 -J
. F ? 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
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT ITO 10=C.F.M.) 4.00
CONSTRUC'r1ON LENDING AGENCY AIR HANDLING UNIT(OVER 10,000GF.M.) 6.00 SEISMIC FEE IY'
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
-it. 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 Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC ,
�Ip 1 rtify Thar I have read this applicmion and slate that theabove VENTILATION FAN (SINGLE) 4.00
unisinmatiun is correct. I agree to comply with all city and county PLUMBING
odinances 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 elver upon the BOILER-COMP (Over 100,000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
011 agree to save, indemnify and Is harmless the City of MISC.- REFER TO ORD.
Cupertino ag.inst liabililie- judgments, costs rd efipenses which CONST.TAX
may, in any way accrue gm sed City inonsc uence of the PERMIT ISSUANCE 10.00
mnfipg of Ibis pennipl. MECH.CONT. LIC.NO. MECH.
\nn Lei` "Alk, J TOTAL TOTAL ��
Sl lyatdreo A Tgnt Contraclor Date
INSPECTOR COPY