8513 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL8513
O fl'
NAME PLAN CHECK VALIDATION
. QTY. ELECTRIC PERMIT FEE
RAO OF rUPFRTINO 14EI 252-.70'A7
CONTRACTOR'S
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00 V-
bag H&mes . Inc , LIC.-o-323864 LIGHTING FIXTURES 10.00/1.00
ADDRESS roR's APPLIANCES-RESIDENTIAL 4.00
20823 Stevens Creek 81 c
PHONE252-20 PANELS 10.00 ( DATE OF APPLICATION
oR PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
GRANDE" ". C009375SIGNS TRANS. 3.00
ADDRESS 18008 SKYPARK CR .N20 SPECIAL CIRCUIT 5.00 VER�M, QgTtoN
JiNfi, CA Z1,95711 EMP.METER OR POLE INS. 20.00 Y�
ADDeEss 20823 Stevens Crk Blvd MOTORS SEE FEE SCH. AUG 201985
SERVICE CHFWGE 20.00 - J
o ¢ i
0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE`;- 30.00 City e of Cu
c illo
1 hereby affirm that I am licensed under provisions of Chapter 9 p '`
z Aw ISSUANCE DATE
waw (commencing with Section 7000)of Division 3 of the Business and B ELECT. PLG. MECH.
F D z Professions Code,and my license is in full force and effect ❑ ❑ ❑
z O- - License Clau Lic.Number 13��qppy&4-
j o N_- Dale Contractor iitl-S--R8i1F
aY � � 1rlV
I.Lr ¢ w a OWNER-BUILDER DECLARATION BUILDING PERMIT
o d U INFORMATION
Ir w g a- m I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u 0 J Law for the following reason.(Sec.703 I.S.tlusincss anJ Prof IS VALUATION $/FT.
- PERMIT ISSUANCE 10.00
w � Code:Any city orcounty which requires a permit tocuunlort,alter,
a Oimprove,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
0¢ requires the applicant for such permit to file a signed statement that TOTgL
6 W m he is licensed pursuant t0 the provisions of the Contractor's License PERMIT TO
H z i
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
4 o Business and Professions Code)or that he is exempt therefrom and QTV. PLUMBING PERMIT FEE nk
¢ I- o the basis for the alleged exemption.Any violation of Section 7031.5 STORI -TYPE CONSTR.
s 3 m
by any applicant for a permit subjects Om applicant to a civil penally
Of not more than five hundred dollars(S500).): ALTER-DRAIN& VENT-WATER (EA.) 5.00 y /
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 GROUP RES:UNITS
-their wle compensation,will do the work,and O,C structure Is not
intended or offered for Sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 $Q FT. LOOR AREA T TALACREAGE
- ]temshimself re of rote de own employee
s,S provided that such improve.
orimprovmentisn old roffiewithin
year o If,howevee tile the owner-
GAS-EQ.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion,the awncr-
builder will have the burden of proving that he did not build or im, GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 R IND CON PB Omer
❑ I,as owner of the Property,an, CxclusivCly contracting with ❑ ❑ ❑ O f
licensed contractors to construct the project (Sec, 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 1 ASSESSORS PARCEL NO.
1 and Pro fesslons Code:The Conm,adnr's License Law docs not apply
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 contractor(,)licensed purwunt to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ 1 Sm exempt under Sec._,B&p.C.for this WATER HEATER W/VENT 6.00
lease,
Ow"ef lra'p WATER SYSTEM 5.00 ACGDATE ACC.FILE NO.
WORKERS'COMPENSAPION DYCLAKA'FION WATER TREATING EQUIP. 5.00
` I hereby affirm (far I have a artificute of consent to sell-insure,
ar Xcerlifiertc of Workeri Compm,mtion Insumncc,or i c,,Iili,d ZONING ENG.SITE NO.
copy thereat' Scc.3800,Lab CJ.
Policy No�]p,t1 pDfJ .Q_Rar" -
O ((]] Certfedc a f her, en 4 FIRE SPRINK ENERGY T 24
Z Z O CertifAp•d py s fled with the city inspect inn livision.
Appfcam-jy.A��.0 Mlnewr•u MISC- REFER TO ORD.
F � �o��-u- 0-I-1'I- Y ❑ N Y ❑ IN
it CERT IFICATE OF EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZON si A.L.UC.
LU > COMPENSATION INSURANCE . PLG.CONTR. LIC.NO. PLG.
CIL O 1'fhu section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
:D Z hundred dollars IS 100)or Iv,Q
- U O I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner sit as to
O become subject to the Workers'Compensation Laws of California.
w Date Applicant BUILDING
u ALTER OR ADD TO MECH. 5.00
} W NOTICE TO APPLICANT: If,Site,making this CrRificatc of Ex-
F Z emption,you should become subject to the Worked Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
1 U- such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=11F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE �-
s 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
I 3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
•r I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information a correct. I agree to comply with all city and county
ordinances ad state laws relating 10 building construction, andd BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
hereby authorize representatives of this city es enter upon theb.veBOILER-COMP (Oval 100,000 BTU)SEE FEE SCH. MECHANICAL
_ hereby anthmimtioned pDepeity mive,or pef this
purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
granting of this permit, MECH.CONT. LIC.NO. MECH. - -
TOTAL TOTAL �� ,3
ria ore of Applicanl/Contractor )ate ,
u INSPECTOR COPY -