8329 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN Oy N Y
d BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING / APPLICATION & PERMIT w
DRESS !
BUILDING- ELECTRICAL-PLUMBING-MECHANICAL F l�
OVINER PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
• A LCO PARK LTD PHONE
CONTNAAMERAcrpRs UTLETS-SWITCHES-RECEP 10.00/1.00
_ OILS FIRE PROTECDIc rig 09 LIGHTING FIXTURES 10.00/1.00
CONTRACTOR S
ooEssTORS APPLIANCES-RESIDENTIAL "B AV 4.00
2 30 Blaoow Rd. P480-2844 PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CMECK.FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00 ,,.:_ .,
ENGINEERLIC.NO. SIGNS TRANS. 3.00
ADDRESS eNc. SPECIAL CIRCUIT 5.00 PVMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ADDRESSPPLI rs MOTORS SEE FEE SCH. n
el
-� SERVICE CHANGE 20.00 ��)
•� o FoLICENSED COIVIRACTORS DECLARATION TEMP.POLE 30.00
G z U/ 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
`- ca
to Q1, (comnleneing with Section 7000)of Division 3 of the Business and BLD ELECT. PLG. MECH.
n rvy z Pru fie aionx C Idc,,rod Iny license is in full fofce and effect ❑ ❑ ❑
.1 0 o w a Liwnsc las _Lia Num
w r w Ilalc Contra h�
a Y a BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDER DECLARATION
S,
a v INFORMATION w
X. ; u y I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
F LL o j Low for the city
...:R reason.(Sec.7031.5,tlrnut to and Professions
PERMIT ISSUANCE 10.00 VALUATION $/FT.
E w > f Code:Any e,dcuryor mu ntywhiny requiresa Penni ttocrnsuance.also
r- -
¢ ¢ Q O improve,demolish,of repair any slnmture prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC. {
D ¢ requires the applicant for such permit to file a signed statement that TOTAL J PERMIT TO -'1
e is m m he is licensed pursuant to the provisions of the Contractor's License
Hz }
Law(Chapter 9(coumencing with Section 7000)of Division 3 offle
¢ Bubasis for the alleged
and I'rofcaslons Code)or that he is exempt therefrom and QTV. PLUMBING PERMIT FEE J
s 0 tic d exem
./ ¢ H o gr, exemption.Any violation of Section 7031.5 ST RES TV E CONSTR:
n =' by any applicant for a pemlit subjects the applicant toa civil penalty
of not more than five hundred dollars(5500).): ALTER-DRAIN& VENT-WATER (EA.) 5.00re 4
sI ❑ I,as Owner of the property,or my employees with wages as BACK FLOW PROTECT. DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
11 intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
SCode:The Contractor's License Law does not apply to an owner of
o property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SET FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsare not intended or offered for sale.If,however.the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owners GAS-EA.SYSTEM OVER 4(EA.),„L 2.00 BUILOING USE
=`+ budder will have the burden of proving thallic did not build or mr; qEs -IND D - PB Other,
prove for purpose of salol C..' INDUSTRIAL WASTE INTER. 130.00 -� --
Q O 1,as owner of the property,anac
t exclusively cont ting with
S� t heeased comumctors to construct the project(See.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORSrARCELNO.
`!.Ii• and Professions Code I he 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 contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ tum exempt under Sec. ,B.&I'.C.for this
reason WATER HEATER W/VENT 6.00
i
Owner Date WATER SYSTEM 5.00
4ACC.DATE ACC.FILE NO.
WORK IiRS'COMPENSA'I'ION DECLARAr ON WATER TREATING EQUIP. 5.00 '
i l
'II herchy affirm that I have a certificate of consent to selcinsure' ZONING:
fJ /` or a certificate le of Workers'Compensation Insurance,or a mtlified ENG.SITE NO,
Co�(yp�y(��yIhemnf(Sec.3900,fLah.0-l.(b�!�\��
0., I'A31kC�idloi' P-y'Is llhy l untishc��W FIRE SPRINK ENERGY T-24
Z Z IL] Certified copy is fled with the city inspection division. MISC- REFER TO ORD.
O Applicant V ❑ IN V ❑ NE]
F rn ,, PERMIT ISSUANCE 10.00
LU - 1 CI:R1H7ICA'fCOI'I:XI:MPr10N FROM WORKERS' FLOOD ZONE A.L.U.C.
W > COMPHN'SA'601,1 INSURANCE PLG.CONTR. LIC.N0.CL PLG N�
+' Z I ('Phis Section need not be completed if the permit is for one TOTAL V N v
humdicd dollars(SIO0)orless.)
> U O I certify that in the performance of the work for which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY •
LL f i mit is issued,I shall not employ any person in any manner so as to
U becorric suhject to the W'orks,,Conlpcnsatirn Laws of California.
O y�� Date 1' Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N, NOTICE TO APPLICANT': Il;after making this Certificate of Ex-
F" 2i cmpfion;you should become iGbject In the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
'.' provisions of the Labor Code, you must forthwith comply with FEE 3/•�%
CJ such provisions or this permii shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M) 4.00
1" 01 AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE Al
I 1f 1 CONST RU ION LENDING AGENCY
I hcrebyluffirn that t ere is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 +'
the performance of the work for which this permit is issued(See ROMICFILM
3097;Civ.C.)., HEATING UNIT(TO 100,000 B.T.U.) 8.00 _
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC'
Lend'er's Address
I certify that I have read this application and state that the above4B(,OILER-OOMP(3H.P.orlOO,000B.T.U:I
ENTILATION FAN (SINGLE) .4.00
,'• information is correct I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, Bad 6.00hereby authorize roperty forins ec chis city es enler upon theILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
herebymauti orizared preprese for iesp of th purposes.,(Wel agree to save, indemnify and keep harmless the City ofISC.- REFER TO ORD.
fir I; Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST-TAX
I' may in any way accrue against said City in consequence of the j+
f granting of this pent MECH.CONT. LIC.NO. MECH.
�� TOTAL TOTAL
.i 1 r icant/• n- c or Date D ./
INSPECTOR COPY
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