C8151 APPLICANT TO FILL IN IN"FORMATION WITHIN RED LINES ,- USE BALL POINT PEN ONLY
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BUICDINGPROJECIMNTIFICATtON " PERMIT NUMBER
ADDRESS -. APPLICA�I U PERMIT
BUILDING
O � r - q .� • ' BUILDING-ELECTRICAL=PLUMBING-MECHANICAL
OWNERS L/ - PLAN CHECK VALIDATION
NAME y QTY. ELECTRIC PERMIT FEE
ONE
NAMEaT Rs �' OUTLETS-SWITCHES-RECEP 10.00/1.00 k
uc.No.�� LIGHTING FIXTURES 10.00/1.00
c NRR To 's Sc1n C5i PPLIANCES-RESIDENTIAL 4.00
ADDRESS ] �(gyp
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'7'
n GPDGNE PANELS J.G.OD DATE OF APPLICATION
7
AUPUCPI EC - % J PANELS (OVER 200 AMP) 2000 PLAN CHECK FEE P.C.NO.
ENGINEER
<,, , uc.NO. SIGNS TRANS. - 3.00
nDDRESSE SPECIALCIRCUIT 5,00 PERMIT VALIDATION
1 , 4 . zIPCy EMP.-METER OR POLE INS. 2OZO,
API+
ADDRESS v
MOTORS SEE FEE SCH.
r1 SERVICE CHANGE 20.00
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LICP:NSEU CONTRACTORS DECLARATION TEMP.POLE 30.00
a U I hereby affirm that I am licensed under provisions of Chapter 9 L .ISSUANCE DATE
y < n (commencing with Section 7000)of Division 3 of the Business and
BLDG: ELECT. PLG. MECH.
F m z Professions Code,and my license is in full force and effect.� ❑ ❑ ❑ ❑
z 0,A- License lass c. Lic.Number ��
9 w t w Date Contractor
a M f � BUILDING PERMIT
a rc a OWNER-BUILDER DECLARATION
0 0 o INFORMATION
w ; w I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
F LL O a Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE �X0 ( VALUATION $/FT.
So
Code:Any city or county which requires a Penn it(o co;tract.alter, / ' Q
2 rt Q improve,dem Wish,or repair any structure,prior to its issuance,also ELEC.CONED. LIC.NO. ^• ELIC.
a orO u requires the applicant our such permit to file a signed statement that TOTAL / 3 PERMIT TO
m m he is licensed pursuant to the provisions of the Contractor's License
Fz>•
Law(Chapter 9(conmencingwith Section 7000)ofDsision 3 of the
i o Business and Professions Code)or that he is exempt therefrom and QTY, PLUMBING PERMIT FEE S�'s/GGC JAe9�y.
te m- the basis for the alleged exemption.Any violation ofSection 7031.5 STO ES TYPE CONSTR.
m
a3 _ by any applicant for a permit subjects the applicant a civil penalty ALTER-DRAIN&VENT-WATER IEA.) 5.00
error
more than five hundred dollars(S500).): pl•� S N rye
❑ I,as than
of the property,or my cmploGtrtu
y'erwith wages as gAC�C.F LOW PROTECT.DEV ICE 4.00 OCC.GROUP REB.UNITS
their sole compensation,will do the work,and (he Cre is nbt"^�
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 F- 3
property who builds or improves thereon,and who does such work 1 FIXTURES-PER TRAP 5.00 1Z ed -SD.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improv'- .-
mentsarenotintended or offered for sale.If,however,the building It GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00 mm ;;L s�
or impveenl is sold within Una year of completion, w
the owner-- GAS EASYSTEM-OVER 4 IEA ) 200
builder will have the burden of proving that he did not build or int - . . .
- BUILDING USE
m, prove for purpose Of sale.). , INDUSTRIAL WASTE INTER3000 RES IND CON PB Core,
. .
❑ 1,as owner of the properly,am exclusively contracting with ❑ ❑ ❑ ❑
I licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:Time Contractor's License Law dons 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 contractors)licensed pursuant to -
theConlractor'sLicenseLaw. SEWER-SANITARY-STORM EA.200ft/10.00 — TRACT NO. PARCEL NO.
❑ I aru exempt under Sec.—,BAP.C.for this WATER HEATER W/VENT 6 4[ —
reason
Owner [)ale WATERSYSTEM 00
1 eJ• f1 ACC GATE ACC.FILE NO,
WORK FRS'COMPRNSAI'ION DECLARATION WATER TREATING EQUIP. 5.00 t
I hereby affirm that I have a certificate ofconsenl to self-insure. ZONING ENG.SITE N0.
or a certificate of Worker:Compensation Insurance,or a certified
copy(hereof(Sec.3800,Lab.C.).
Policy No. Company
O Cl Certified copy is hereby furnished.
FIRE SPR INK ENERGY T 24
Z Z rt:tied copy I- fled wish mile city inspcc(ion division.
p App I D—:neck- e - MISC.- REFERTOORD. Y ❑ N❑ _ Y ❑ N❑,
CC �- CERTIFICATE 017 EXEMPT[ON'FROM WORKERS' 'PERMIT ISSUANCE 10y_00 � FLOODZONE A.L.U.C.
LU > m CO!, 'NSATION INSURANCE: PLG.CONTR. LIC.NO, PLG, /
Z ('Phis section need ..I he Completed if file permit is for one - TOTAL '�Q•� Y❑ N❑ V[:] N❑ L
hundred dull...($100)or less)
Q
I certify (hat in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
Date—Applicant - BUILDING s.
} rail NOTICE: TO APPLICALTER OR ADD TO MECH. 5.00
NT': IC afar making this Certificate of Ex- S `✓
Z_ eruption,you should become subject In the Worker Compensation APPLIANCE 5.00 PLAN CHECK
provisions of (he Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked AIR HANDLIN UNIT(TO 10)000C.F.MI 4.00
.CONSTRUCTION LENDING AGENCY AIRHANDLING UNITIOVER 10=C.F.M.) 6.00 SEISMIC FEE „SZt
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the ,erfo...nnce of rhe work for which On,permit i,a issued(Sec MICROFILM
3097,Civ.C.)., HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name e ,=x 1C
Lender's Address �..� - �P3_y<my,�r� HEATING UNIT(OVER 100,000 B.T.U.)9.50 V ELECTRIC 3
1 certify that I have read this application and state that the above 14 VENTILATION FAN (SINGLE)a� 4.00
• information is correct. I agree to comply with all city and county - PLUMBING tN
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.or100,000B.T.U.) 6.001 70
hereby authorize representatives ins ec (his city m enter upon (he BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL 3.s-12-
(We)
�
aereby autioniz property for inspection purposes. J S
(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 CONSTTAX /
may in any way accrue against said City in consequence of the / 1
gran(ingolthisper...iL MECH.CONT. LIC.NO. MECH.
g I Il TOTAL 3s TOTAL /OS-3
Smgnatuao Apple (Cont 'tor ale
INSPECTOR COPY /
1