C8469 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
11, BUILDING PROJECT IDENTIFICATION ` PERMIT NUMBER
/\
EndLININGING APPLICATION & PERMIT j / ��
7411 S BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S - PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
NG)Fw Ml I_.,x &V PHONE ;
CONTRACTORS
NAME r OUTLETS-SWITCHES-RECEP 10.00/1.00
17/J UNi /I:17MI�"li (UMrb LICA No. & 09'(, LIGHTING FIXTURES 10.00/1.00
f.ONTRACTo !
ADDRESS APPLIANCES-RESIDENTIAL 4.00
(.LµaS)N✓i Sf PHONE Sy,"Y/I PANELS 1Q,QQ DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
rev frEMP.METER OR POLE INS. 20.00
Ars
ADDRDDREESSSSMOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 1' '
'02
0o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 \ / /)
a m0 u I hereby affirm Hort I am licensed under provisions of Chapter 9 \ISSUAN11 CE DA E
N Z i
(commencing with Section 7000)of Division 3 of the Business and SLOG. (ELECT: PLG. MECH.
,-, w O Professions Code and my license,s in full force and effect. ❑ ❑ ❑
im G DteLicense Class - _Lic.Nwnhcr�
F m H j Dulc Cant rector
a >! Y e .7 BUILDING PERMIT
¢ ¢ w a OWNER-BUILDER DECLARATION
o a u INFORMATION
K
; LL H I hereby affirm that 1 an,exempt from the Cmifinctor's License MISC.- REFER TO ORD
H LL o se Law lot the following reason.(Sec.7031,5.Businessond Professions PERMIT ISSUANCE VALUATION $/FT.
E4Code:Any city orcounty which requires a permit to construct,alter,
w 1000
0 �A JI
2 ¢ a O improve,demolish,or repair any structure,prior to its issuance.also ELEC.CONTE. LIC.NO. ELEC.
So
O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
u w m m he is licensed pursuant to the provisions of the Contractor's License
z a
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 O Business and Professions Code)or that he is exempt Iherefrour and CITY. PLUMBING PERMIT FEE 9/ J 11
¢ H mthe basis for the alleged exemption.Any violation o(Setl run 7031.5 STORIES -TYPE CONSTR.
aF, by any applicant fore permit subjects the ALTER-DRAIN& VENT-WATER (EA.) 5.00cantacivil penalty
Of not more than five hundred dollars the applicant
m
❑ 1,as owner of the property,or my evrployecl witl,wages us BACK FLOW PROTECT. DEVICE 4.00 DOC GROUP
flEs.uwTs
their sole compensurion,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Prou,jons DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
e himself or through his own employees,provided that such improve-
armsarenotintended or atfered for sale.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
Of improvement is Sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or ice- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of sale.). RES IND CON PB Other
❑ I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑
licensed contractors In construct the project(Sec 7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. 1 6.00 - ASSESSORS PARCEL NO.
and professions Code:The Contractor's License Law docs not apply
to an owner of property who builds or Improves thereon.and who LAWN SPR INKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contmctood licensed pursuant to SEWER-SANITARY-STORM EA.200f1110.00
the Contractors License Low. TRACT NO. PARCEL NO.
❑ 1 um exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK BRS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
-, I hereby affirm that I have a certificate ofconsenr to self-insure. ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a Certified
copy thereof(Sec 3800,I.ah.CJ.
Policy No7.$I---%f0o,npany 5T.TE; uyro
O ❑ Cerlilied c'opY is hcmhy furnishetl' FIRESPRINK ENERGYT24
z Z4 Certified copy is lil}-d ith the city inspection division.
O Aplicanr / '� MISC.- REFER TO ORD. Y [:] N� Y [-] NE]
~ y PERMIT ISSUANCE 10.00
UJ CCRTIFICAI'EOElA% I NT INS FROM WORKERS' FLOOD ZONE A.L.U.C.
' W � COM.,'f be completed
INSURANCE PLG.coNTfl. LIC.NO. PLG. Y� N� Y [J IN
d O hundred
action need not be completed if the permit is for one TOTAL
� Z hundred dullaa(S 100)or lea.)
V O I certify that in the performance of the work for which this peQTY. MECHANICAL PERMIT FEE FEE SUMMARY
Q. F mit is issued,I shall not employ any person in any manner so as ror-
O become subject to the Workers'Compensation Laws of Calilorniu.
V a Date Applicant ALTER OR ADD TO MECH500 BUILDING
.} W NOTICE TD APPLICANT: II',after making this Certificate of Es- . . /1//
Z emprion;you shroud became subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you nwst forthwith comply willi FEE
V Incl,provisions or this,rmrem
it sliall be ded revoked AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
1 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.CJL HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
NHEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Names ELECTRIC
I certify that I have read this application and state that the shove VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state lows relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives ins inspection
this city to corer union the g01 LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly forinsp of 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 again said try in consequence of the
granting ofUtasermiL MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL �2
w i
Signator PAPP icant/Con u<to Dae
INSPECTOR COPY _