8394 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
J BUILDING Loi s- APPLICATION & PERMIT .�V 4
J` ADDRESS
"If-L" ` BUILDING-ELECTR!,CAL-PLUMBING-MECHANICAL _
OWNER$
NAME'I- PLAN CHECK VALIDATION
. ^n QTY. ELECTRIC PERMIT FEE
"'KY'1/� PHONE ��>� ',1
NAIIVEnaCTcroRs OUTLETS-SWITCHES'-RECEP 10.00/1.00
1 LIC.NO. LIGHTING FIXTURES 10.00/1.00
ADDRESSTORS PPLIANCES-RESIDENTIAL 4.00
1 PHONE PANELS 10-00T- DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.N0.
on PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC NO SIGNS TRANS. 3.00
ARCH,
DD Ess ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
zip TEMP.METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCH. ('
aooRBs
SERVICE CHANGE 20.00
0 0 J
, LICENSED CONTRACTORS DECLARATION I TEMP.POLE N_00 jY/d s
a z I hereby affirm that I to.licensed under provisions of Chapter 9 - ISSUANCE DATE
H Q H (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r D z Professions Code,and my license is in full force and effect
0 0 v°i License Class Lia Number
H m H o w We-Contractor
a >< fBUILDING PERMIT
it u' w 4 OWNER-BUILDER DECLARATION INFORMATION
w3:3 r I hereby affirm that I um exempt from the Contractor's Licem'c MISC. REFER TO ORD W
uOv, Law for the following reason,(See.7031,5,Businessand Professions 0.0.E + VALUATION $/FT.
I- - PERMIT ISSUANCE _•-
Code Any city or warty which structur a permit o cls issuance,
,also 1 J
2 R Q improve,demolish,or repair any structure,prior toils issuancq also ELEC.CONTR. LIC.NO. ELEC. /.� /�3 U Q v
LL requires the applicant for such permit to file a signed statement that TOTAL /> !/'G V
w es m he is licensed pursuant to the provisions of the Contractors Litems PERMIT TO
H so Q Law(Chapter 9(ccomp"cingwith Section 7000)of Division 3 oftht VlrCv
E D Business and Professions Cole)or that he is exempt therefrom and QTY- PLUMBING PERMIT FEE -
or H m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES E CON
by any applicant for a pennitsubjectsthe applicant toe civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500).)' / S"�u /.,�j`-
❑ Las owner at the property,t or my employees with wager us BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will Jo the work,and the structure is not --�
intended or offered for Sole (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CONO. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 '_ $0.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
rents are not intended or offered for sale.If.however,the building GAS-EA.SVSTEM-11NC.40UTLETS Ct.00 a.2 /LS•f
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose ofsale.). RES IND CON PB Other
thproperty,. INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑
❑ I,as owner of the property,um exclusively contracting with
licensed contractors to construct the project(Sec. 7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Coda:The Contractor's License Law does"ot apply
to on owner of propertywho builds or improves thereon,and who LAWN SPR IN KLERS-OVER 5(EA.) 100
contracts for such projects with a contractor(s)licensed PURna0110 SEWER-$ANITAR V-STORM EA.2001t/101(N) L 0 S
j the Contractor's License Law. TRACT NO. PARCEL NO.
Cl tum exemp a Jer Sec. ,B.&P.C.Ivor this WATER HEATER W/VENT 6.00
reason _
Owner '° g_ Date WATER SYSTEM 5.00
J �� //JJ-- / .cam ACC.DATE ACC.FILE NO.
N'ORKERS'COh I'IiNSAI'10(DEC LA RATIO' ' WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-i.,u c,
or a certificate of Workers'Compensation Insurance,or a certified C. ZONING ENG.SITE NO.
copy thereof(Sec.3800,fair CA
Policy No. - Company
C ❑ Certified copy is hereby famished,
Z 0 ❑ Certified copy is Filed with the city inspection DivisionFIRE SPRINK ENERGY T-24
I. -
Fp Applicant I MISC.- REFER TO ORO. Y ❑ N❑ 'Y ❑ No
PERMIT ISSUANCE 10 d FLOOOZONE A.L.uc.
LL > O
LUT - CERTIFICATE Nl E PION A(TI PT RPROM WORKERS' s
I'I'his Section need ooN be completed if het-permit is for one PLG.COrvTR. -' uC.N0. PLO
TOTAL G Y E) N❑ v❑ NEIao
U O hundred dollars(S100)or less.)
I certify that in the performance of the work for which this per- OTY. MEC ANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner so as to
C L) become subject to the Workers'Compensation Laws of California.
y Dec ApplicantBUILDING
>_ to NO'rl Cli TO APPLICANT': IL Ilfmr making his Certificate of fix- ALTER OR ADD TO MECH. 5.00 O�)
F Z emptier,you should becmnt subject to the Workers Cmnpensution APPLIANCE 5.00 PLAN CHECK
t provisions of life Labor Code, you must forthwith comply with FEE
U Such provisiuns or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 _
CONSTRUCTION LI,NDING AGENCY AIR HANDLING UNIT(OVER 10=1C.EM.) 6.00 SEISMIC FEE 6/
I hereby-affm, that there is a construction lending agency forEXHAUST HOOD(WITH DUCT) 5.00
tire
performance of he work for which this permit is issued(Sec. 72 MICROFILM
3097,Civ.C.T HEATING UNIT(TO 100,000 B.T.U.) 8.00 yG
Lender's Nome HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 94 -
1
Address ELECTRIC
1 certify that I have read this application andstate tlwt the above VENTILATION FAN (SINGLE) 4.00
:flonnation is cornet. I agree Ie comply with all city and county PLUMBING
eminoncer and s6tc laws relating to building construction, unA BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 (O
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100.000 BTUI SEE FEE SCM. MECHANICAL
above inentioned property for inspection purposes. V
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judg, Pres, costs and expenses which PERMIT ISSUANCE x,00 CONST.TAX
may in an way acej�sec against hid City in consequence of the LA
granting is mtjl' MECH.CONT, LIC.NO. MECH.
td• TOTAL S- TOTAL
Sign A p"Eirfir)(Cftactbr ate / %/0 �•
INSPECTOR COPY