8179 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - L I P Nf1N•6y 'ea
BUILDING PROJECT 1 DENTI FICATI ON PERMIT"UMBER
...DING APPLICATION & PERMIT �� ��
c'
ADDRESS UILDING -ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S yny PLA LIOATION
"AME Q� MT (+� OTY. ELECTRIC PERMIT FEE
PHONE •�
NAME AD R UTLETS-SWITCHES-RECEP 10.00/1.00 AUG 12j IJ )C`"'
ND. LIGHTING FIXTURES 10.00/1.00
CONTS:21`0.15 I APPLIANCES-RESIDENTIAL 4.00 CB7 bfi Cupertino
ADDRE
KANHON PANELS 10.00 DATE OF APPLICATION
ONCHiron'll PANELS (OVER 200 AMP) 20.00 r1 PLAN CHECK FEE P.C.No.
ENGINEER U /
o, SIGNS TRANS. 3.00
ADDRESS ENc. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS
ADDRESS MOTORS CHANGE SEE FEE SCH.
SERVICE 20.00
woo LICIiNSEU CONTkACTORS DEC ;RATION TEMP.POLE 30.00
a u, I hereby affirm that I am licensed node,pmvisuHR of Chapter 9 ISSUANCE OATEef'`
fl
y a a (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. MECH.
m i Professions Code,and my license is in full force lin 1 eff; t
License Clens Liu.Number SFA'I_f
Q m r Dale Contractor
a >< E ��' BUILDING PERMIT
¢o a U O - UILDER DIECLAR I INFORMATION
w3LL I, I hereby affirm that I ani exempt from I h c Co a tractor's Li cc l MISC.- REFER TO ORD
ac La w for the following reason.(Sri.7031.5,N usmess and Profen' as PERMIT ISSUANCE 10.00 VALUATION $/FT.
f �AP,4 Code:Any city or county which requires a permit to construe eller,
rt a a D improve,demolish,or repair any structure.prior to its ism ce,also ELEC.CONTR. LIC.NO. ELEC.
0 u requires the applicant fur Such permit In file a signed sn neat tial TOTAL PERMIT TO
w m he is licensed pursuant to the provisions ofthe Contra ons License
F Z i
Law(Chapter 9(commencing with Section 7000)of vision3ofthe a^,
a Business anJ Professions Code)or that he is esen t therefrom and QTY. PLUMBING PERMIT FEE Y VI
IS o the basis for the alleged exemption.Any violati of Section 7031.5 STORIES TYPE DONSTR.
es.aim by any applicant for a permit subjects the app ant to a civil penally ALTER-DRAIN -WATER IEA.) 5.00
0f not mora than five hundred dollar.1550
❑ 1,as owner of the property,or m no Ityces with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the w ,and the structure is not
intended or offered for sale (Sec. 7 4, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License L' does not apply to an owner of
properly who builds or improve hereon,and who does such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTALACREAGE
himself re through his own a red for
sale.provided that such improve-
meals mselfo throuhhisot oro redfor ,o,idlow'evt s the building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
0r improvement is sold w' in one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the b en of proving that he did not build or im- BUILDING USE
prove(or purpose ofs c.). INDUSTRIAL WASTE INTER. 30.00 RES IND O PB Other
❑ I,as owner o the property,am exclusively contracting with ElEl El Ellicensed contract - ah construct IIIc project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS RCE.NO.
and Professions -ode: rhe Contractors License Law does not apply'
to an owner properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contrudsf such projects with annntnmor(s)lic"nscd pursuant. SEWER-SANITARY-STORM EA.200ft/10.00
111c Cont ctor v License L,.. TRACT NO. PARCEL N0: .
❑ m exempt under Sec. ,B.&RC.for this WATER HEATER W/VENT 6.00 '
• ,Cas
O er Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSANON DECLARATION WATER TREATING EQUIP, 5.00
I hereby affirm that I have a certificate of consent to self-insure.
or a certificate of Workers'Comp" Sul" Insurance,or a certified ZONING ENG SITE NO.
Copy min of,.(Sec.3800,.AC.L
Policy N0�Vi fflg y_.
Q ❑ Ccr I i c I y(m iea. FIRE SPR INK ENERGY T-24
z z Certilled copy Is tiled will the city "Pec Pon division.
O Ati Tcanl MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
N CER " AI'i P :XGA fi'P [ k PERMIT ISSUANCE 10.00 FL000 zorvE A.L.u.c.
W > COMPENSATION INSURA K1: PLG.CONTR. LIC.NO. PLG.
� Z (This section need not be completed if the permit is I'or a TOTAL V❑ N❑ v❑ N❑
hundred dollars IS 100)or less)
U O 1 certify that in the performance of the work for which is per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mil is issued,1 shall not emplRy any pinion in any man ,so as to
O Q become subject to the Worker Compensation Laws o ali(ornia.
n Date Applicam BUILDING
} N NOTICE:TO APPLICANT:/INLISt
making this .enificat"of Ex- ALTER OR ADD TO MECH. 5.00
F 2 enlption,you should becomto the Wo a Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Cmust I thwith comply withFEEsuch provisions or this permdec it revoked. AIR HANDLING UNIT(TO 10=GF.M.1 4.00CONSTRUCINGAGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
I hereby affinn that Ihenstruction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the soich this permit is issued(Sea / MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000B.T.U,19.50 ELECTRIC
Lender's Address
I certify ilia I hav read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
information is cor a. t agree to comply with all city and county PLUMBING
ordinances and ate laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby autho eC representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-men
Y ned property for inspection purposes.
(We) Nee to save, indemnify and keep leorde. the City of MISC.- REFER TO ORD.
Caper' o against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may n any way accrue against said City in consequence of the in nR oft ermh MECN.CON. LIC.NO. MECN.
TOTAL I G
Sign' se e Ppli t o )'le J
'ImmEclCOPY