8745 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
" BUI LD1 NG PROJECT I DENTI FICATI ON ` PER
ran LOING APPLICATION & PERMIT
ADDRESS 8745 7 A I•FJC
10670 '�dIIt$I3 BUILDING - ELECTRICAL-PLUMBING-MECHANICAL fV5
OWNER'S _ PLAN CHECK VALIDATION
NAME - QTY. ELECTRIC PERMIT FEE
• Val 1co Park Limitad ONE
OMERAcroRs
NUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No. r LIGHTING FIXTURES 10.00/1.00
ADoFs
ADDRESSDRESS APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 FLAN CHECK FEE p,C.NO.
ENGINEER
LIC,No. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 - PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
AMOTORS SEE FEE SCH. ^
ADDRESS OREss
1 SERVICE CHANGE 20.00
,0 o LICENSED CON"TRACTORS DECLARATION TEMP.POLE 30.00 (� r{`
a v u I hereby affirm (list I am licensed under provisions of Chapter 9 ISSUANCE. T I
hw (commencing with Section 7000)of Division 3 of the Business and
a uAi BLDG. ELECT. PLG. MECH.
H H z Professions Cnde,and my license is N full force and effect. ❑ ❑ ❑
z o m - License Class_�9�--Lic.Number
Q z E o Da(c�[fo [nNW--Contractor
Q y f Vim'V �J ti ^ BUILDING PERMIT
rc Ic w a" OWNER-BUILDER DECLARATION
d o a u INFORMATION
'w g I heaby ullinn (lira I em exempt (lora the Contrnetor's License MISC.- REFER TO ORD
u o j Law for the following reason.(Sec.7031.5.Husinessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
� - w Code:Any city orcounty which requires a permit to construct,alter,
2 ¢o improve,demolish,Or repair any structure.prior to its issuance,also ELEC.CONTR. WG NO. ELEC.
- O LL requires the applicant for such permit to file a signed statement that TOTAL
a w m he is licensed pursuant to the provisions of the Contractor's License PERMIT i0
>
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
z a
4 o Nosiness and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE �Z
K H p the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
u ;W by any applicant1"or a perm it subjects(heappliamt to a civil pmmtly ALTER-DRAIN -WATER IEA.) $,00
of riot more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044. Business and Professions _DRAINS FLOOR,ROOF,AREA,CON D. 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 FIXTURES-PER TRAP 5.00 56 FT.FLOOR AREA TOTAL ACR EAGE
• himself or through his own employees.provided that such Improve-
ments are not immured or offered for Sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvemem is sold within one year of completion, the owner
builder will have 0¢
burden of proving that he did not build or ire- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of sale J' INDUSTRIAL WASTE INTER. 3000 RES IND CON pe Omar
O 1,as owner of the property,ran exclusively contracting with .
licensed contractors to construct the project(Sec.7044.BusinessLAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code.The 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 SEWER-SANITARY-STORM EA,200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ turn exempt under See.-,BAP.C.for this VATEH'H EATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSAIION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a Certificate of consent to sell-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sce.3800,Lab.C.).
Policy No. Company
O ❑ Certi15M I y H hereby f FIRE SPRINK ENERGY T 2
Z Z �-pv Gertlfied copy is filed with the city inspection division. MISC. REFER TO ORD.
O A1y1�'lie"ant _ Y N Y N
CC T) *'*V'�2 1 f ROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LLI > COMPE NSA I NL R ANCE PLG.CONTH. ❑C.NO. PLG.
Il Cl ❑ N❑ [3 ❑
(This section need not be completed if the permit is for one TOTAL Y Y N
::) Z hundred dollars IS 100)or less,)
U O I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner so as to
O w become subject to the Workers'Compensation I.aws of California.
a Uatc Applicant BUILDING
} to NOTIGII TO APPLICANT. If,after maki III, tificafe of ISx- ALTER OR ADD TO MECH. 5.00
emption,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you nose Ihr(hwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm (hal 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
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Calder's Addreaspt�� ELECTRIC "
I certify that I have read this application and state that the above VENTILATION 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. and BOILER-ODMI I3 H.P.or 100,000 B.T.U.) 6.00
hereby, authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property'for inspection purposes. �Z
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino ag hua liabilities,)pdgtnent], COMB and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
rimy in any way accrue against said City in consequence of the (JS$
grsnLng o(Ihis permit. MECH.CONT. LIC.NO. MECH.
8 -�\ OTAL C TOTAL
Sigheture 9 ntractor I -'Dat-Daze
�
INSPECTOR COPY