C8439 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENT[FI CATION PERMIT NUMBER
IWILOING APPLICATION & PERMIT /
Ao.R ss Imo//
BUILDING -ELECTRICAL-PLUMBING -MECHANICAL
OWNER PLAN CHECK VALIDATION
'`t AME• y��n���k� _ S_ QTY. ELECTRIC PERMIT FEE 36 ''" ,-�(,1 �C��7
of ,.OR,- r ,�-U ""
NAME�OlerRA TD s UT LETS-SWITCHES-RECEP 10.00/1.00
Ic. 4/4 LIGHTING FIXTURES 10.00/1.00
cb T sT0 APPLIANCES-RESIDENTIAL 4.00
L� RONE PANELS 10.00 PATE OF APPLICATION
A CHITS , • /Ok n s' H I /J J PLAN CHECK FEE P.C.NO.
OR / 'V !`'.E�4' PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.No. a SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5,00 PERM IT VALIDATION
ZIP TEMP. METER OR POLE INS. 20.00
APPLI MOTORS i SEE FEE SCH.
ADDRESS
SERVICE CHANGE 2000. {
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
iu I herchy affirm that I um licensed Ruder.....visions of Chapter 9
(commenPS
(11 Section 70001 of Division 3 of the Nusiness and ISSUANCE DATE
G °' 1 BLDG. ELECT. PLG. MECH.
� �Z Professioc,an y Iauc is in full fore• h _
o0 s, 'Licfc Lie.Number
0 Date Contract
o
M y IS J
K ¢ w c 'NSR-BUILDER DECLARATION RnT1oN BUILDING PERMIT
K
; u I hereby affirm that am exac.7 from the Con,..actor s License
MISC,- REFER TO ORD INFORMATION
F w o g Luw,for the Ihllowing reams.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 1 0 .VALUATION $/FT.
Code:Any city or county which requires a permit to construct,atter, � /
rt ¢ ¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
G LL requires the applicant for such permit to file a signed statement that TOTAL / Q I PERMIT TO
n w m m he is licensed pursuant to the provisions of the Contractor's License
� z >
Law(Chapter 9(commencing with Section 7000)of Division 3 ofihe
4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
r m the hasis for the alleged cxelnplion.Any viOlal ion of Section 7031.5STOR S TYPE CONSTR.
of not than
fora permit cuhjeds the applicwt ton civil penalty
more
twn flvcbundred dollars($5000T: ALTER-DRAIN& VENT-WATER (EA.) 5.00
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not DCC.GROUP RES.UNITS
intended or offered for sale(Sec. 7044, Business and Professions 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 does such work F IXTUR ES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himse. mems are not hrough
ownemred for sale.
If,ed ever.the
improve GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
mems are not intended or offered for sale If,completion
the building
or impbuilder
will have
is sold within one year of cam dict ion,the owner-or
builder will have the burden of pronng that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 - BUILDING USE
prove 1.as owner
of sale.). INDUSTRIAL WASTE INTER. 30.00 RES INP CON PB On.,
❑ L c owner of the property,he exclusively contacting with
licensed contractors to construct the project(Sec.7004,Business LAWN SPRINKLERS-i INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Codec The Contractor's License Law Joos not apply
to tr owner of property who builds t r improves thereon,and t to LAWN SPRINKLERS-OVER 5(EA.) 1.00
commas forst License
ects Lwith ucontaciods)licenced pursuant to SEWER-SANITARY-STORM EA.200tt/10.00
the Contrne,ois License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,B.&P.C.for alis WATER HEATER W/VENT 6.00
eased
Owner Date WATER SYSTEM-., 5.00 ACC.DATE ACC,FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 v
•vllll��((IF��/•• 1 herchy affirm ,hot I have "ca I ofcnnsent to self-insulc,
or a certificate of Workers•C mpens Lion Insjhranee,or a ce tried ZONING ENG.SITE NO.
copy,hcr gg44_�,
CJ.
Policy N Iy
O 1 ❑ Q y f
Z Z FIRESPRINK ENERGY T-24
��py' ..til o y0 Aldhlic n, MISC.- REFER TO ORD. Y[J No Y ❑ NE]
rn CERTIFICATE 01'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.O.
W > COM1IPENSA'1'ION INSURANCE PLG.CONTE. LIC.NO. PLG.
CL 0 (This Section need not he completed if the permit is for one TOTAL Y❑ N0 Y D N�
2 hundred dollar.IS 100)or less.)
00 I certify that in the performance of the work I'or which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL,tI- mit is issued,I shall not employ any person in any manner so as to
OI L) become subject to the Workers'Compensation Laws of California.
y Date Applicant BUILDING -
}• w NOTICE'1'0 APPLICANT: If,alter making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
F Z emptlon,you should become subject to the Workers'Compensation APPLIANCE5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with i FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
h 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.C.). - HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lenders Name HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC W
I information
that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• ordinances n correct.I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING `-
ordinances eori state laws relating to building construction, and
hereby authorize representatives of this arty to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH.
above-mentioned property for inspection purposes. MECHANICAL -2 �,u
(We) agree ,o save, indemnify and keep hunnlecc tie City of MISC.- REFER TO ORD.
Cupertino against liabilities,-judgrtx.pIs, costs and exp ues dict PERMIT ISSUANCE 10-00 CONST.TAX
ma in any way accrue against said City in cause Ace the p
gra ng of this permit. MECH.CONT. LIC.NO. MECH.
A _ ' TOTAL 7 4.0 TOTAL c�C.
INSPECTOR COPY ✓'
I