9452 APPLICANT TO FILL IN INFORMATION WITHffiV REDrLINES - USE BALL POINTPEN ONICY,.
BUIL'DINGPROJECTIIDENTIFICATION PERMIT NUMBER
APPLICATION & PERMIT
auILOINc � ^
ADDRESS -
y' n BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 45 2
4 .
WN RB PLAN CHECK VALIDATION.
I NAME
257_7000
DTV. . 1 ELECTRIC PERMIT FEE
oNE
. .' NA�IERAcrORs `.lo OUTLETS r,SWITCHES-RECEP 10.00/1.00 D9 00
S c No. LIGHTING FIXTURES 10.00/1.00
ro RAcrons PPLIANCES-RESIDENTIAL 4,00 -
ADDHEss 510 W. San Fernando St.
PHONE
ORCA 9%115 -9979 PANELS 10.00 DATE OF APPLICATION
Ir c PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEE
' eWlett Packard uc:No, t - SIGNS TRANS. 3.00
ADREErvc. p ]RnPSPECIAL CIRCUIT 5.00 PERMIT VALIDATION
i ziP EMP.METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCH.
ADDRESS , 510 W. San Fernando St. 1
Ran loqe.� CA 9511% SERVICEICHANGE 20.00 R
0 0 LICENSED CON"TRACTORS DECLARATION TEMP.POLE / 30.00
a G_\. If 1 hereby affirm tlmt 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
n a w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
FAN z\ Professions Code,and my license Min full force and effect ❑ ❑ ❑ ❑
Z, o m - License Class �.1�-Lic.NLumber--no 'j
I'.0 L Hx�w Uate Contractor
Q x ¢ a OWNER-BUILDER DECLARATION r BUILDING PERMIT
a 0 a OINFORMATION
! w ; LL I- I hereby affnm Thal 1 am exempt from the Contractor's License MISC.-. REFER TO ORD
n. O< Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 1000 VALUATION $/FT.
I L Code:Any city or county which requires a permit to construct,itheq
n
se p Q 0. Improve,demolish.or repair any structure,prior to Its Issuance,also ELEG CONTR. LIC.N0. �.
ELEC.
- O ¢ requires the applicant Ibr such permit to file a signed statement that M. -Butcher 1 TOTAL PERMIT TO
u w m u he is licensed pursuant to the provisions of the Contractor's License
HZQ Law.(Chaptcr9(comencingwith Section7000)of Divisiot3ofthe
¢ o Businmess and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r e the basis for the alleged exemption.Any violation of8ection 7031.$ 1
I STORIES TYPE CONSTR.
d3cO by any applicant lin a permit subjects the applicant too civil pcnglty ALTER-DRAIN -WATER IEA.) 5.00 -
of not more than five hundred dollars(85001.):
❑ 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCG GROUP RES.UNITS
sole compensation,will do the work,and the structure is not
intended or offered for sale(Sea 7044, Business and ProfessionsDRAINS-FLOOR,ROOF,AR EA,CON D. 5.00
Cod,:'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.Fr.FLOOR AREA TOTAL ACREAGE
• himself re through his awn employees,provided that such improve
or improvnotement is sold w thinoffered
onefor
year
If,however,the building GAS-EA.SVSTEM-1 INC.4OUTLETS 6.00
or improvement is e burden within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have thu ale.). of proving That he did not build or im- BUILDING USE
prove 1,aso nee of the.). INDUSTRIAL WASTE INTER. 30.00 RE5 IND CON PB Omer
❑ ed as owner of the property,he exclusively( e contracting with ❑ � ❑ 11
licensed contractors : construct the project ISec. 7044,Business LAWN SPRINKLERS-1 INC S V.B. 6.00 ASSESSORS PAR CEL NO.
and Professions Coda:The who
builds i License s th dos nal dwho r
to tr owner of property who builds tr improves thereon,and t to LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects wish a mntrucmds)licensed pursuant to
' the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
.ca
lam exempt under Sec. ,B.&P.C.tin this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK FRS'COMPHNSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to sell'-insure,
or a certificate of Workers'Compensation Infampse.ora cerjl ficd ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab. .074-9.3aj•QO! �m
policy No. - ompan _
O ❑ Certified copy is hereby F. I . Ut FIRE SPRINK ENERGY T 24
z Z _§j Ce copy is filed w It the 'y speclion division.
3F O �TTicat MISC.- REFER TO ORD. NE] Y [:) NE]
y .CIi RTIFI 'I'1i OF EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOOZONE A.LU.C.
W > fl (.OIPFNSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d o (This'section need not be completed if the permit is for one TOTAL YE] NE] V0 NEI
::) Z hundred doll.rs(S 100)or less.)
U 0 1 certify that in the performance of the work for which this Per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL F- nut is issued, 1 shall not employ any person in any mm�ner st as to
become subject to the Workeri Compensation Lucas of California.
0. Date Applicam ALTER OR ADD TO MECH. 5.00 BUILDING
>_ m NOTICE TO APPLICANT: IL after making this Certificate of He-
f� cmption,you should becamesubject to the WorkersCompensation 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 revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0=C.F.M.) 6.00 SEISMIC FEE
'I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance o1'the work for which this permit is issued(Sec. MICROFILM
301 Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Ic motion
that Ihave read this application and statethattheabove VENTILATION FAN (SINGLE) 4.00
• ihformdtion is correct I agree to comply with all city and coum Y' PLUMBING
ordinances andstatelaws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00
hereby uulhorim representatives of this city to enter upon the
above-mentioned property for inspection purpouBOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
s.
(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 ace Ie a• fund said City in consequence of the PERMIT ISSUANCE 10.00
gra Ig of this pcnni MECH.CONT. LIC.NO. TMECH.
: c
TorAL TOTAL `
I la eofAgvrco t/ on tilt"" Date r • -
INSPECTOR COPY