8328 A� APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDINGUp p iHtt� I APPLICATION & PERMIT
ADDRESS I
'Q� BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
' O
328
OwNERa PLAN CHECK VALIDATION
NAME
1.�.CQ �AQ.Y.. DTV. ELECTRIC PERMIT FEE
vuorvE
CONTRACTOR'S
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00 f
♦� ud.No. 3 LIGHTING FIXTURES 10.00/1.00
DRESSTOR'S kT fNI� n6V l
-ADDRESS \/ Tx PPLIANCES-RESIDENTIAL 4.00
IBA J]D NIY PHONE ff' PANELS 10.00 DATE OF APPLICATION
OORC NE L ,LF{L\D01(. �SP�� yAIPF PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0.
thg. �,^ L,C.NO, SIGNS TRANS. 3.00
ADDRESSon G' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
aIS11sa R1 , 1pV'JI ZIP
144 EMP.METER OR POLE INS. 20.00
AMOTORS SEE FEE SCH.
ADDRESSDDRESS
SERVICE CHANGE 20.00 94
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
FZ W I hereby affirm that I am licensed under provisions Of Chapter 9 9 ISSUANCE DATE
¢ vAi (Commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H w z Professions CoJ d my license is in full f mLe f c ❑ - ❑
z O m - License Class Lia Number e�
O y F i' Date COnlmetOr
axa Z$bWNE BUILDING PERMIT
¢ Ix ¢ N'NIi R-BUILDER DECLARATION
o a-v INFORMATION
F
3 U-y 1 hereby collo that I am exempt from the Contractor's License MISC.,- REFER TO ORD
LL o a Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code Any city or county which re4uiresa permit toconstruel,otter,
BE K ¢ p improve,demolish,or repair any stieclure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
�0
n w m BE requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
he is licensed parsua t to the provisions of the Contractor's License
H z i
Law(Chapter 9(commencing with Section 7000)of Division 3 oftle
z o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE I AJ
T I-m the hasis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
La by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER IEA.) 0 t
of not more than five hundred dollars(S500)J:
❑ 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,COND. 5.00
Code:The Comr,etorh License Law does not apply to an owner of
property who builds or improves thereon,and who does such workFIXTURES-PER TRAP 5.00 SOFT.FLOORAREA TOTAL ACREAGE
• himself'or through his own employees,provided that such Improve-
foods
mprove-
meats are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
or improvement is sold within one year of Completion,the owner- GAS-EASYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or int- . BUILDING USE
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON pB Omer
O 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to Construct the project(Sec. 7044,Business LAWN 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 contractorts)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
-❑ 1 am exempt under Sec. B.&P.C.lin this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACG FILE NO.
. WORK F-RS'COMPFNSAT ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate Of Consent to Sclf-insure, _ ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a cert i(icd
copy thereof(Sec.3800,Lab.Clrn
Policy No. CompayV Len j Rl
U ❑ Cerli ed copy is hereby(u( F S� FIRE SPRINK ENERGY T 24
z Z ❑ Cerci 1 A 7 s (Sled wl e a inspection div" n. MISC.- REFER TO ORD.
p Applicant ` Y❑ N❑ Y ❑ N❑
~ va PERMIT ISSUANCE 10.00
- :RTI PICA 'OF EST i 11'1'IUS UN WORKI> FLOOD ZONE A.L.U.C.
W CO. F.NSAT NINSU NCIi PLG.CONTE. LII].NO. PLG
d Q This s "n-ncud'nol be comp if7the permit is for one TOTAL Y❑ N❑ Y❑ N❑
D Z hundred dollars 151001 or less.)
U O 1 ecnify that in the performance of the work In,which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mil is issued,I shall not employ any person in any manner so as to
U
U become subject to Ilm Workers Compensation Laws of California.
0.- Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ mNOTICE TO APPLICANT: U',alter making this Certificate of F;x-
(_ Z ennption,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U Such provisions or this permit shall be deemed rcvnked.y AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGI!NC-Y AIR HANDLING UNIT(OVER I0,000GF.M.) 6.00 SEISMIC FEE
I 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.Crv.C.L 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 1 have read this application and state that the ahove VENTILATION FAN (SINGLE) 4.00
information is correct.I agree to comply with all city and county PLUMBING -
Onlinances end 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 I
above-umotioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE,FEE SCH. MECHANICAL
(We) agree'to'saveP indemnify and keep harmless the City of MISC.- REFER TO ORD. .�
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
m in an wayaccm nst said City in consequence of the
PERMIT ISSUANCE 10.00
gra his ting _ MECH.CONT. ' /+ LIC.NO. MECH.
TOTAL TOTAL
ignalure fAp locant/ ntractor Date
INSPECTOR COPY . .