8512 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT lDENTIFICATION APPLICATION & PERMIT . PERMIT NUMBER
BU DOING
ADDRESS
/l BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 8512
Ow E 5 PLAN CHECK VALIDATION
NAMEQTY. ELECTRIC PERMIT FEE
5P n 71
• NAME "L s UTLETS-SWITCHES-RECEP 10.00/1.00
uc.No.
z LIGHTING FIXTURES 10.00/1.00
ADDRFAcrol�j5 {��ens Creek B1%
PPLIANCES-RESIDENTIAL 4.00
OC
2C vUr r PHONE 252-2O PANELS 10.00 DATE OF APPLICATION
0pcHlTecr PANELS (OVER 200 AMP) " 20.00 PLAN CHECK FEE P,c.No.
,NG
INEEP
RJ K * c.No. SIGNS TRANS. 3.00
A PERMIT VALIDATION
ESS 8008 SKYPARK CR. #200 SPECIALCIRCUIT 5.00
TOUTRIE CA zIP EMP.METER OR POLE INS. 20.00 ���
ADDRESS MOTORS SEE FEE SCH.
APPLIcA
�C2C.2Q$� r����enEACr�s�id SERVICE CHANGE 20.00 UG 2U 1985
woo LICENSED CON'I'RACTORS DECLARATION TEMP.POLE 30.00 - City OI CUpp��r�{{
¢u u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE IsA`Y�IIIU
¢ n (comming with Section 7000)of Division 3 of the Busiand j
�r ¢ i
H m,AencBusiness and
Professions Code,and my license is in Cull farce and effect 4r BLD . ELECT. PLG. MECH.
El2 o m - License Class' Lie.,Wtmber _
, z
t w Dale-4-f_I 6 Contractor F
¢ m f BUILDING PERMIT
¢ Ir: ¢ OWNER-BUILDER DECLARATION
oa" - MISC.- REFER TO ORD INFORMATION
X ;LL vHi I hereby ullinn that 1 am exempt from the Contractor's License
.. o¢ Law for the following reason. 7031.5,Business and Profess ions PERMIT ISSUANCE ' 10.00 VALUATION $/FT.
i - Code:Any city orcounty whichreceiresaperniuoconstruct.alter, _
¢ A �. improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.rv0. ELEC.
_ O 2 requires the applicant Cur such permit to file a signed statement that TOTAL I PERMIT TO .r e
A w m he is licensed pursuant to the provisions of the Contractor's License
us i i Law(Chapter 9(commencing with Section 70001 of Division 3 of the
¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
r¢o r the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
La
A ;'w' by any applicant for a permit subjects the applicant to a civil penalty /
of not more than five hundred dollars(S500).): ALTER-DRAIN III VENT-WATER (EA.) 5.00
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 oC OUP ES.UNITS
their sole compensation,peation,will do the work,and the structure is not
/. intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CONO. 5.00
Code The Contractors License haw docs not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 $0.F .FLOOR AREA Tor ACREAGE
• himself or through his own employees.provided that such improve- GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
mints are not intended or offered for sale.If,however,the building
or improvement is sold within one year of con...co n,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will Imve the burden oCpovog that he did not build or i:n- BUILDING USE
prove for purpose ofole.). INDUSTRIAL WASTE INTER. 30.00 s IND CON PB Omw
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
rrh r licensed contractors to construct the project tSec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
I'r and Professions Code:The Contractor i License Law does not apply
• I to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
r r' contracts for such projects with a contmetons)licensed pursuant to " -
OmContractor'sLicenseLaw. SEWER-SAN ITARV-STORM EA.2001t/1 0.00 TRACT NO. PARCEL NO.
!� O lam exempt under Sec. ,B.&BC.for this WATER HEATER W/VENT 6.00
reason
\, Owner Date WATER SYSTEM 5.00 ACC,wesIV ACG FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
rr I hereby affirm that I have a certificate of-consent to self-insure.
rr r
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG,SITE NO.
copy there°1'f5ec 38�0j0p,�L(InbQ.C'.Jl.�j.p���.�pp
'i Policy No..G.7.11-C1�fltlVyliul1K-d. n�Lfk ' fVR�
/��O � Cem to t / FIRE SPR INK ENERGY T24
r i Z Z .i Certified coy s filed with the city inspection division.
Jli O Appbcaot_ggS-C-F GUP- I*I�'tf!-i-H- MISC.- REFER TO ORD. y ❑ N r ❑ N❑
~ va PERMIT ISSUANCE 10.00
CERTIFICATE OP I ATIOTION FROM WORKERS' FLOOD ZON A.L.U.C.
LU > ' COAIPI!NSATION INSURANCIi PLG.CONTR. LIC.NO. PLG,
CL O / (firs section need not be completed if the permit is for one TOTAL Y❑ N❑ y ❑ N❑
� Z hdndred dollar,IS 100)or less.)
�I0U O , I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued.I shall not employ any person in any manner so as to
become subject intim Workers Compensation Laws of California.
ORy)
/ a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NO'T'ICE 1'O APPLICA N"P: If,after making this CerIIflcatc of Ex.
Z enhption,you should become subject to the Workers'Compensator 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 10,000C.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNITIOVER 10,000C.F.M.) 6.00 SEISMIC FEE _
I hereby affirm that there 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 Name HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
® information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws refuting to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authurice representatives of this ehy to enter upon the BOILER-COMP lover 100.000BTu1 SEE FEE$CH. MECHANICAL
above mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless tine City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 �-
grnningoCthispermlt. MECH.CONT. LIGNO. MECH. '
TOTAL TOTAL fGf/3 fe
I• ata h n nn rector Du O
i ., INSPECTOR COPY
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