8508 APPLICANT TO FILL:IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT I DENTI FICATI ON PERMIT NUMBER
B,nLmNG APPLICATION & PERMIT
'. ADOREss '
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 8508
OWN R
rvnmE PLAN CHECK VALIDATION
DTV. ELECTRIC PERMIT FEE
BAS OF CUPERTINO,-1-1I
CONTRACTORS
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
bas'..Nomes Inc: Luc.... 323864 LIGHTING FIXTURES 10.00/1.00 `
cONTRACTORa APPLIANCES-RESIDENTIAL 4.00
ADDRESS 20823 Stevens Crk 91 v
PHONE PANELS 10.00 DATE OF APPLICATION
pR PANELS (OVER 200 AMP) 20.00 PLAN CHECKFEE P.C.NO.
ENGINEER
No SIGNS TRANS. 3.00
A C G.
ADDRESS 18008 Sky park Cr . A20 . SPECIAL CIRCUIT 5.00 j�� PERMIT VALIDATIONy.�
pe, CA Zi EMP.METER OR POLE INS. 20.00 T_�D
" WIN
MOTORS SEE FEE SCH.
ADDRESS 20823 Stevens Crk Blvd
AUG 2 U
SERVICE CHANGE 20.00 1985
° ¢ TEMP.POLE 30.00
Foo LICENS17D CONTRACTORS DECLARATION �y tt
< u w I hereby affirm that 1 am licensed under provisions of Chapter 9 City �II E
n (commencing with Section 7000)of Division 3 of the Business and
< A BLD ELECT. •PLG. MECH.
H w i Professions Code,and my license is in full force and effect ❑ ❑ ❑
Z O License Class�.p.�.�Lic.Numhcr
D w r w Dam ��_L Yf[-CContractor- Q�$-
srm 2 � •�� `� l ne BUILDING PERMIT
¢ ¢ st OWNER-BUILDER DECLARATION
F o a L' INFORMATION
X g a w I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u• o¢ Law for thrity.'ingreas.n.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
r - Code:Any city or wu my which requinni permit to construct,alter,
¢ ¢.,a 0 mtprove,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. ^a r
Il ° ¢ requires the applicant fur such permit to file a signed statement that TOTAL
1 o u PERM IT TO
I Wm heispursuant toting provisions of the )o f Division
Licen3 of the
( JHza
Law(ChapterProcosionsCde)ng or Section is exempt therefoofthe r
re E D
Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢ H m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE Cp ttN TR.
by any applicant for a permit subjects the applicant to a civil penalty .ALTER-DRAIN& VENT-WATER (EA.) 5.00 C� A7b
ot m
of more than five hundred dollars($500).): I v
❑ 1,as owner of tire property,or my cniploy,es with Wages a$ BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work.and the structure is not
'y intended or offered for sale(Sec. 7044, Business and ProfessionsDRAINS-FLOOR,ROOF,AREA,COND. 5.00 r
Code:'file Contractor's License Law does not apply m an owner of
r property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 So.F .FLOO AR A TOTALACREAGE
himself re through his own employers.provided that such.....rove"
means throuhh isot onempoffered for ees,sale.provided
that suhchuilding)owc- GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion, the owner - . - . .00- GAS EASYSTEM OVER 4 (EA ) 2
_ builder will have tum burden of proving that he did not build or int- a ILDING USE
prove for purpose of sale.). R S IND CON PBS Omit,
Cl 1.as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 El L.❑
!� licensed contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORSFARCEL NO.
and Professions Code:The Contractor's License Law dues not apply' y
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 ,
contracts for such projects with a contractins)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00
.J the Contractor's License Law. TRACT NO. PARCEL N0.
❑' 1 and enempt under Sec. ,B.&P.C.for this WATER HEATER W/V ENT 6.00
/ reason
Owner Date WATER SYSTEM 5.00
j ACt.CrATLIACC.FILE NO.
WORKERS'COMPIiNSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate rf consent to self-insure. ZONING ENG.SITE N0.
or 4,ertificate of Workers'Compensation Insurance,or a certified
copy thereof, Sec 3800,Lab C.. p,�,�J
/ Policy No. Nr�u 2 g�}a�°'t-rVT't�
�+ O V❑ Cent lle�dcopy is " y((urnisYsrd. FIRE SPRINK ENERGVT-I4 t'
r z Z z1] Certified o y fled with the 'ty inspection division.
O I Applicant_-AA-��''- '.�-P-�R�IT�u TZ 11- MISC.- REFER TO ORD'. V No V ❑ N❑ t
~ w_+ I� PERMIT ISSUANCE 10.00
LU i CIi IFICATE EXEMPTION FROM WORKERS' FLOOD ZONE A.L.u,C.
W � COMPENSATION INSURANCE PLG.CONTR, LIC.rv0. PLG.
CL O ` (This svetion need not be completed if the permit is for one TOTAL Y❑ NC] Y E) NE]
Z) Z hundred dollars(S 100)or less.)
U 011 certify that in the performance of the work for which this per- QTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL, H aI is issued,I shall not employ any person in any manner so as to
U brcoDic subjecttotile Workers'Compensation Laws of Culifuri ia. 1
'� orDat,, Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} m NO"rICE '10 APPLICANT': If,after making this Certificate of lix-
F Z emptfYn,you should become subject to the Wurkeri Compenmtion APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such praLisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1of.10DC.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10E000EM.) 6.00 SEISMIC FEE
I hcrehyl,affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
PI 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
1 Lender's NA--ame
Lender's Pia HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify thgt I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00n.
infimnalion ilm-reI ogre,to wmply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordiwnces and+state laws relating m building construction, and
hereby authorirepresentatives of this city to enter upon the BOI LER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mention property for inspection purposes.
(We) agree to save, indetmnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, Costs.and expenses which PERMIT ISSUANCE 10.00
I , CONST.TAX
may in any way'aecmu against said City in consequence of the
gmn[ing of this perinit' MECH.CONT. LIG NO, MECH.
ITOTAL
i aur ppGcant/Contramor ,Date• TOTAL
r 7 INSPECTOR COPY