C8516 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENT]FICATI ON PERMITNUMBER
Bu
Lm Nc - APPLICATION & PERMIT
AOORED p(/qM E7}(t--(1S DEk/ C-O
2 : BUILDING- ELECTRICAL-PLUMBING-MECHANICAL
INNER'S x PLAN CHECK VALIDATION
NAM/ CT2 EE rvt Geo P40M� �aS OTY ELECTRIC PERMIT FEE
: . Cvh N PHONE UIS
LONTR
NAME UM - 24K35 UTLETS-SWITCHES-RECEP 10.00/1.00
uO.NO. l ' LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
ADDRESS
APPLIANCES-RESIDENTIAL 4.00
-i PHONE Lfq(. PANELS 10.00 DATE OF APPLICATION Fr~
ARCNITECT :I PLAN CHECK FEE P.C.N0.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
U , (e-.. uc.NO, SIGNS TRANS.
i ADDRESS ENG
.SPEC.IALC.IRCUIT .,5.00 PERMIT VALIDATION
2,R EMP.METER OR POLE INS. 20.00
avv LlRa rs MOTORS SEE FEE SCH.
aooEss ���,
SERVICE CHANGE 20.00
° ¢
r O o C LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a v u I hereby affirm that I am licensed under provisions of Chapter 9 'ISSUANCE DATE
w z w .(commencing with Section 7000)of Division 3 of the Business'undl
BLDG ELECT. PLG. MECH.
H s i L 'ysions Code,and my license L . in full force and effect
z o License Cl a Llc.Number "�A' 1")
DateConlraaor
yJ
a WN13R-BUILDER DIiCLARA ON BUILDING PERMIT
ow
as INFORMATION
M
L,
; u m I hereby affirm that i am exempt from the Contractor's License MISC.- REFER TO ORD
u
r _ d VALUATION $/FT.° j Law for the followingreason.(Sec7031.5,BusinessanPessions PERMIT ISSUANCE
10.00
Code:Any City Or mu oty whiny structur a FlefmU to cons issuance
alter
IS Q p as improve,demolish,or repair any structure,poor tD.lt6 issuanm,also ELEC.CONTR. LIC.NO. ELEC.
° a: requires the applicant for filch permit to file a signed statement that TOTAL P Mtt - V
u w sa m he is licensed pursuant to the provisions of:the Contractor's License
Hz � Law(Chaplr
e9(Commencing with Section 7000)of Division 3 oflhe
s �.
a Busineand Professions Code)or that he is therefrom and QTY. PLUMBING PERMIT FEE _
r ca ,the basis for the alleged exemption.Any violation of Section 7031.5 O E CONST H. /
u , by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN (EA)15.00
of not more than f - - .
ve hundred dollars(8500).)- ,1
O I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE _°U.00 OCC.GROUP RES.UNITS'
their sole compensation,will do the work,and the st ruclure is not
_ intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 sa FT.-FLOOR AREA TOTAL ACITE
himself or through his own employees,provided that such innprove-
mentsarenotintendedorofferedforsale,If,however,the huilding GAS-EA.SYSTEM-1 1 NC.4 OUTLETS 6.00
or intprovennent Is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or int- BUILDING USE
p u e for purpose of sale.). ,. RE IND CON PB Other
❑ -as owner of the 'am x exclusively INDUSTRIAL WASTE INTER. 30.00 1:1 El 1:1 El ,Y. 7044,contracting
licensed'c7onhado6 lslconstru 1 the project(S 7044,Business LAWN SPRINKLER$- 1 INC 5 V.B. 6.00 ',j, ASSESSORS PARCEL NO
andProfessions Code:The Contmdor's License Law does not apply u r _
to an owner of property;who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1:00 4
contracts for such projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. - _ TRACT NO. PARCEL NO.
❑ Pam exempt onde-r Sec. - B&PCIm,11i WATER HEATER W/VENT 6.00 ps':>; c>.,
reasoqq
O n ry - Ume WATER SYSTEM 5.00 ACC.DATE - Acc.w 6N0.
WORKLRS'COMPENSAIION 917CLARATION WATER(TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate C to of consent 1 t t self-insure,
or u certificate of Workers'Compensation Insuraneclor a mrtified ZONING ENG.STENO.
copy Bnereof(Sec.3800,Lah.C.F
Policy No. Company /
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGYT24�
Z Z rerifed copy 0 fled with 11, ei inspection division.
FO AlRlheartIn ^- MISC.- REFER TO ORD. Y � NF] Y ❑ NE]
� N CIi R'I'IIICA"E PEXEMPTIO FROMMORKERS' . PERMIT ISSUANCE ! " 10.00 FLOOD ZONE _ A.L U.C.
W > COMPENSATION INSURANCE - PLG.CONTR LIC.DIP PLG.
CL 0 (Chis section need not be completed if thepcnnit is for one ,.or, TOTAL Y❑ NE] V E] IN 1:1
"Z_„j hon died do l let,IS 100)or less.) -
U O I certify that in the performance of the work for which this per- QTY. _ MECHANICAL PERMIT FEE FEE SUMMARY
U mit is issued,I shall not employ any person in any"enact so as to
become subject tO the Workers''Compensation Laws of Cullforuit.
a Data Applicant ..* ALTER OR ADD TO MECH. 5.00 BUILDING /
} ti NOTICE 'ID APPLICANT': If,*after nwking this Certificate of
F✓_ Z otnption,you Should become subject to the WOrkers''Compensation't APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith mrlPly'Willi FEE e
Such provisions or this permit shall be deemed revoked'. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LiLADING AGENCY AIR HANDLING UNIT(OVER IO,ODOGF.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
theperformance of the work for Willett this permit is issued(Sec. MICROFILM S
3097,Civ.C.) HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name IliI6Ma `
Lender's Address HEATING UNIT(OVER 100;000B.T.U.)9.50 ELECTRIC
1 certify that 1 have read this application and state that tire above VENTILATION FAN (SINGLE) 4.00
• information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives ins inspection
on city es color upon the BOI LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for insp 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 l CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE. 10.00
granting of t s permit. MECH.CONT. LIC.NO. MECH.
q1 1415,
TOTAL TOTAL 3
Signature c Ap cenl/Co roc[ 041c,
INSPECTOR COPY