C8156 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
ROILDING APPLICATION & PERMIT
ADDRESS e
x � a f , o No ,P- BUILDING -' ELECTRICAL-PLUMBING-MECHANICAL
'/ NERB `` PLA HECK VALIDATION
x NAME N' Qf T�•h
S V6V41JOG'C� - QTY. ELECTRIC PERMIT FEE
ONTtyj('QHI� Y J PHONE fj-Q�OI
A TOflS
NAME V UTLETS-SWITCHES-RECEP 10.00/1.00
lVUtii LIC.No. Z LIGHTING FIXTURES 10.00/1.00
I ss CONTRACTORS Al ^4 APPLIANCES 4.00
ADDRESS 7 S(' I
PHONE PANELS 10.00
_ S �' DATE OF APPLICATION
ARC E T�n C`�C 4 R FN PANELS (OVER 200 AMP) 20,04 PLAN CHECK FEE P.C.NO.
on 3 0�5r(,"
ENGINEER
'uc.No. SIGNS TRANS. 3.00
ARCH,OR ENG, PERMIT VALIDATION
ADDRESSSPECIALCIRCUIT 5.00
�5f rV M//.t/![=f 3r` � }gyp
zIP If TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
/N -1130 t/<_' SERVICE CHANGE 20.00 i
woo LICENSED CONTRACTORS DECLARATION
TEMP.POLE 30.00 �5
a i w 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
b¢N BLDG. ELECT. PLG. MECH.
H w z Professions Code, d my license is in full force and effect El ❑ ❑ 1:1
¢ M License Class_I Lie.Number ��2 Af• >
-o'm D'utc rd(�jy'C p Contractor '- y"��
¢ m ¢ ¢ I r OWNER-BUILDER DECLARATION BUILDING PERMIT
a o o u INFORMATION
w ; N I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
.. o¢ Law for the following reason.(Sec.7031.5.Businessand ProfessionspERM1T ISSUANCE 10.00 VALUATION SIFT.
w
Code:Any'city or county which requires a permit to construct,alter, _
ELEC.CONTE, LIC.NO.
¢ ¢ ¢ o improve,demolish,or repair any struqure,prior to LLS issuance,also ELEC. S U Jb�
o u requires fire applicant for such permit to file a Signed statement that TOTAL PERMIT TO
n
X $ o he is licensed pursuant to the provisions of tire Contractor's is Licensc
H z 4 Law(Chapter 9(conimencindewith Section 7000)of t the on 3 of the ,f
ce 4 D Business and Professors Code)or the lie i it tion of ect ion 70 and GTY. PLUMBING PERMIT FEE A a'�
1 ¢ F$ the basis for the alleged exemption.Any violation of Sect ion 7031.5 STORIES TYPE CONS/TR.
d3 _ by any applicant fora permit subjectsthS5e applicant ALTER-DRAIN& VENT-WATER (EA.) 5.00
wcant too civil paucity VN
of not more than five hundred dollars
❑ I,as owner of lire property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC,GROUP RES.UNITS
their sole compensation,will do lire work,and lire Structure is not
intended or offered for sale (Sec. 7044, Business and ProfessionsDRAINS-FLOOR,ROOF,AREA,COND. 5.00 9
Code:The Contractor's License Law dues not apply to an owner of U
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve GAS 8.00
mens are not intended or offered I'or sale.If,however,the building �0 C)
S' ter imptnvement is sold within one year of completion, the owner, GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden o'proving that he did not build m inn- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 --
❑ L as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 P ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
<� to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS'-OVER 5(EA.) 1.00 3 69_�o3
contracts for Such projects with a contractors)licensed pursuant to
7
+' the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL No.
❑ I oat exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
i ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affiint 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.39001 Lab C.).
Policy No. C 0 Pant ! R "4 4.
0 ❑ Certified cop i reby fi shed.
'. n , FIRE SPR INK ENERGY T 24
Z Z ❑ Certified tt y filed n rh the city inspection division.
O Applicant MISC.- REFER TO ORD. Y❑ N❑ v ❑ N❑
CC rn y p�a f` ? t r PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.c.
CERT rIC•'I'). E EXF:MI�YO'�a RRON N' K`F;ItS'
Lu > CO ENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This Section, ne not be completed if the permit is for one TOTAL Y❑ N Y ❑ N❑
Z) Z hundred dollari(S100)or less.)
U O 1 ecilify that in the perf.u,mLe of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mil is issued,I shall not employ any person in any manner so as to
O L) become subject to the Workers'Coni pensation Lawsof Califontia. N
Q_ Dam Applicant BUILDING
} to NOTICE' TO APPLICANT: If,after nicking this Certificate of I.s. ALTER OR ADD TO MECH. 5.00 Q
� Z emption,you should become subject to lire Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of lire Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10000OF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10000C.F.M.) 6.00 SEISMIC FEE la
I hereby Alin t that there is a coostnmtion 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 Name K E -x .J.k,' E =O 2?t
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certlfythat l have read this application and stale that Die above i VENTILATION FAN (SINGL E) 4.00 S
information is correct. I agree to comply with all city amYcounty PLUMBING
ordinances and state laws relating to h54ing construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Uver 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to su^deennify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against I' d'ies,ju tents, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
i may in any w, agai said City in consequence of the
granting of lhi e i / MECH.CONT. LIC.NO. MECH.
k"
OG oTAL TOTAL J.?J-LT
SqOROR&o I elica /Contractor u[e
t INSPECTOR COPY
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