9151 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LOING PROJECT IDENTIFICATION PERMIT NUMBER
ED ROUND
APPLICATION & PERMIT_ 8151
ADDRESS dU�t$r/AJO1 CA .
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
PLAN CHECK VALIDATION
NAME QTV. ELECTRIC PERMIT FEE
PHONE
TRAC 'S
L NAME •OUTLETS-SWITCHES-RECEP 10.00/1.00
/ uC.No. LIGHTING FIXTURES 10.00/1.00
.ONTRACTOR s p PPLIANCES-RESIDENTIAL 4.00
ADDRESS �Ob ALm To S, /fl '
d y ,IgIn PANELS 10.00
S•! 70A!! PHONE DATE OF APPLICATION
onCRITECr PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE D.C.NO.
ENGINEER
/j sec.No. SIGNS TRANS. 3.00
ADDRESS erva � SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zlv EMP.METER OR POLE INS. 20.00
AMOTORS SEE FEE SCH.
ADDDRESSDRESS
SERVICE CHANGE 20.00 �( `
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
M u I hereby affirm thrt 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
y <
((commencing with Section 7000)Of Division 3 of the Business and BLDG. ELECT, PLG. MECH.
H h z Professions Code,and Illy license is in full 11 -e and c 1'c'.
oi w I]� License Class Lic.Nmm' 1A --_ ❑ ❑ ❑ ❑
m H j Dam Contractorobit
a.m 8 �`..�, BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECI-)TiWl( '
IS
eau INFORMATION
K
; I I hereby affirm flint I um exempt from the Contractors License MISC.- REFER TO ORD
F u_ Law tin the following rcavru.(Sec.7031.5,BusinessanA l'mfessions min Ila cp(, VALUATION $/FT.
0 < PERMIT ISSUANCE
Code:Any city or county which requires a permit to construct,alter,
¢ U Q p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
a we ¢ requires the applicant for such permit to file a signed statement that TOTAL a.� PERMIT TO
m¢ he is licensed pursuant to the provisions of the Contractor's License
Fi >
Law 9(commencing with Section 7000)ofDivision 3 ofthe +--
a Business and Professions Code)or that he is exenlpl thereOnm and QTV. PLUMBING PERMIT FEE e/-/d,
It r o the basis for the alleged exemption.Any violation of Section 703 1.5 STORIES TYPE CON TR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wain,as BACK F LOW PROTECT.DEV ICE 4.00
their sole compensation,will do the work,and the structure Is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:ThuContractor's License Law does not apply to an owner of
�- �Oroperty who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO,FT,FLOOR AREA TOTAL ACREAGE
himself'or through his own employees,provided that such improve-
arernot intended or offered for sale,If,however,the budding GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
/. or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving trot he did not build
or im- BUILDING USE
prove for purpose of safe.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer,,
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- I INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:*1 lie Contractor's License Law does 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 contractorls)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor'License Law. TRACT NO. PARCEL NO.
❑ I:un exempt under See.-,B,&P.C.for this WATER HEATER W/VENT-.,, 6.00
reason
Owner Date WATER SYSTEM ` 5.00 ACC.DATE ACG FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. ! 5.00
I hereby affrm that 1 have a cenificate of consent m sel Liosom. /
or a certificate of Workers'Compensation Insurance,or a TONING certified ' / ENG.SITE NO.
/1 copy in-r 3800, of .). A ��
t Policy N E(fitp �� .1R �y '��-
Q ❑ Ce ihedc Is here furfur Islif iedl J4 FIRESPRINK ENERGY T 24
Z 2 vrer(i a cp y is,fled wi the 'ty i peclion division. MISC.- REFER TO ORD.
U Applicant Y❑ N❑ V ❑ N❑
y / ` CI:R1'IPICAI'E OF EXEMPNON roll WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
Z (This section need not be completed if the permit is for one TOTAL Y❑ N❑ N[]Y❑ N
hundred dollars IS 100)or less.)
L) O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,(Shall not employ any person in any manner so as to
U become subject to the Workers'Compensat ion Laws of California.
DO Date *'- Applicant BUILDING
a
ALTER OR ADD TO MECH. 5.00
�- to NO'T'ICE 10 APPLICANT: If,after making this Certificate of Ex-
? cTp6fm,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you Most forthwith comply, with FEE
U .Ssuch provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000OF.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby of inn flat there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the309 ,Cis. C.). e of the work for which this permit is issued(Sec MICROFILM
HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 0
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
inove-mentioned properly for inspection purposes.formation is correct. I agree to comply with all city and county PLUMBING
ordinances and slate laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
abBOILER-COMP(Over 100,000 BTU(SEE FEE SCH. MECHANICAL
(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 "Te o 'nst said City in consequence oC the
granting of this permit MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Igna u
.......le tic nt t r Dan:
INSPECTOR COPY -