C8438 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
BUILDING
BUILDING PROJECT lDENTIFICATION APPLICATION & PERMIT
8 4 3 8
aOOREss
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S � -E�p� PLAN CHECK VALIDATION
/ NAME 1.Y71V\Fes•+ QTY. ELECTRIC PERMIT FEE y✓
I CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
AME
LIC.NO, LIGHTING FIXTURES 10.00/1.00
CONTRAADDRE
croRs
ADDRESS PPLIANCES-RESIDENTIAL 4.00
l .e+(1
HOrvE C3�••) PANELS 10.00 DATE Of APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
oR �t. PANELS (OVER 200 AMP) 20.00
NE 1
LIC.No. SIGNS TRANS. 3.00
ARCH.OR F.G. PERMIT VALIDATION
ADDRESS 35b3 SPECIAL CIRCUIT 5.00
ZIP rEMP.METER OR POLE INS. 20.00
APPLICANT V1,rs
ADDRESS
AU N%21>,Lfi(k- 4SgS MOTORS SEE FEE SCH. �/ S
J W
SERVICE CHANGE 20.00
¢ r 1 c
Hoo LICENSED CONTCLARATION
RACTORS DEG)O TEMP.POLE 30.00
<Z w I hereby affirm that I am licensed mule,provisions of Ch.pler 9 ISSUANCE DATE •!
G u (commencing with Section 7000)of Division 3 of the Business and _ BLOC. ELECT. PLG. MECH.
H o i Professions Cole,and nay license is in full force and effect. ❑ ❑ El Z 0 W - License Class Lic.Number
9 w- 0 Date Contract.,
a m BUILDING PERMIT
¢ ¢o n 0 OWNER-BUILDER DECLARATION INFORMATION
E:
I hereby aft that I:un exempt from the Contractor's License MISC.- REFER TO ORD
.. Da Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
- Code Any city or county which requiresa permit toconstrucl,alteq ,I
'n rove,demolish,or re i u an structure,prior to its issuance.also ELEC.CONTR. LIC.NO.
¢ 6 a 0
improve, Pi Y ELEC. r
Is m m u requires the applicant for such permit to lite a signed statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of lire Contractor's License
z i
Law(Chapter 9(commencingwith Section 7000)of Division 3 oflhe //��
a Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE O'/g'
sio
¢ r m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
ate _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5:00
of not more than five hundred dollars(5500).):
❑ 1,as owner of the property,or my enploy,,I 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,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 FIXTURES-PER TRAP 5.00 SO.FT FLOOR AREA TOTALACREAGE
himself or through his own employees.provided that such improve-
mornsarenotintendedorofferedforsale,If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS EASYSTEM OVER 4(EA ) 200
builder will have the burden of proving that h - . - . .
e did not build or im- BUILDING USE
'prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES IND CON PB Other
O I,as owner of the property,am exclusively contracting with . .
0 0 0 0 0
licensed contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS-1 INC 5 V.8. 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 eornraetoHs)licensed pursuant to SEWER-SANITARY-STORM EA.2001t/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
realm❑ 1 am exempt tinder Sec. ,BAP.C.for this WATER HEATER W/VENT 6.00
Owner 1 WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORK ERS'C051PENSATION DECLARATION WATER TREATING EQUIP. 5.00 .!
I hereby affirm that I have a certificate of eersem to sel Ginsloe, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance.or a certified
copy thersof(Sec.3800,Lsb.CA _
policy No. � Company
❑ Certified copy shereby fUmished. FIRESPRINK ENERGY T$4
Z Z ❑ Certified copy is fled with the city inspection division.
O Applicant MISC.- REFER TO ORD. Y � N� Y ❑ No
~ rn PERMIT ISSUANCE 10.00
W - CIi R'I'I pICATE H .iAEIOI'INS PROMµ'ORKIiRS' _FLDDD ZONE A.L.0 C.
IL need not
our INSURANCE the PLG.CONTR. LIC.NO. PLG. ❑ ❑ ❑ N❑
CL O 1'fhis section need not be completed if the prnnif is f r one TOTAL Y N Y
02 LundreJda twat($I 00)pe less.)
- LL O I certify that in the t irpinuncu y the work for which this per- GTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mil is issued,1 Shn11 not employ any person in nmy manner n,ia to
Ow hecmnc sitbiael to the Workers'Conlpensmiun Luws ol'CWifornia.
Date t lre,at BUILDING
Q. p1' ALTER OR ADD TO MECH. 5.00 .�
>_ to NO]'IC17 '10 APPLICANT: If,after making this C,Uihcam of Ex- _
F. Z emplion,you should become subject to the Workers'Cmnpensnlion APPLIANCE 5.00 PLAN CHECK
- provisions of [lie Labor Code, you I'm', forthwith comply with FEE
U such provisions or this permit shrill be deemed revoked. AIR HANDLING UNIT(TO 10)000GF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby upon 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
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and state that thu above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and9ounty 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 of this city to enter upon the BOILER-COMP (Over 100,0008TU15EE FEE SCH. MECHANICAL
abovrmentioned property for inspection purposes. -
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
g;LlI of this ermil. 1(, MECH.CONT. LIC.NO. MECH.
� � \ is
TOTAL TOTAL S a 7
Signature o nl/ o frac or pale
INSPECTOR COPY
i 4