8569 BUI LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING - - - APPLICATION & PERMIT
ADDRESS
3'? I �,® , BUILDING-ELECTRICAL-PLUMBING--MECHANICAL 8569
DWNE 'S - - PLAN CHECK VALIDATION
NAME (SI
CITY ELECTRIC PERMIT FEE
117-07
PHONE � ID� .
NAMCONE ACTO OUTLETS SWITCHES-RECEP 10.00!1.00
4
i t � LIC.ND. 47p LIGHTING FIXTURES 10.00/1.00 r^ ,
ADDRESS -770
0 s�i - APPLIANCES-RESIDENTIAL 4.00
�`-
R I CT
' .1-- ei z- I _ - PHONE PANELS 10,00: DATE OF APPLICATION.
�H F PANELS (OVER 200 AMP} • 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
LUC.NO. SIGNS TRANS. • p 3.00 I
ARCH.on ENG. - - PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS '
g Ciltd
ADDRESS MOTORS SEE FEE SCH.
.5 SERVICE CHANGE 20.00 f • J'(� ar
•
U.,0 0 LICENSED CONTRACTORS DECLARATION tTION TEMP-POLE 30.00 [J s
av 1 hereby affirm that I am licensed under provisions of Chapter I-- Z w �- 9 ISSUANCE DATE ,
I
cn N 2 (commbncing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLC. tutECH,
Professions Code,and t ens!is in full force and e fe .
n 2- License Class Lic.Number 's v
m e•-m Date i J�;it Contractor J
BUILDING PERMIT
CC a OWNER-BUILDER DECLARA ION INFORMATION
o Q .w-1MISC.- REFER TO ORD
a I hereby affirm that l am exempt from the Contractor's License VALUATION $/FT.
U.0< Law for the following reason.(Sec.703 LS.Business and Professions -y)--I r PERMIT ISSUANCE 10.00
u}�° -Code Any city or county which requires t permit to construct,alter, _ -
¢ a o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELECS
Er o¢ requires the applicant for such permit to the a signed statement that c TOTAL .PERMITTO
X w u- he is licensed pursuant to the provisions of the Contractor's License
ci
g=® Business ndrProfessions Code)or that liSection
e ix exemp00)of tlthe efromivision 3 fthe
and QTY. PLUMBING PERMIT FEE i L� t
cc H a the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.,
mem by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER(EA.) 5.00
of not more than five hundred dollars(5500).1:
_0 I,as owner of the property,or my employees with wages as BACK F LOW 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 SD.FT.FLOOR AREA TOTAL ACREAGE .
himself or through Isis own employees,provided that such improve-
ments are not intended or offered for sale.If.however,the buildingso
GAS-EA.SYSTEM-1 INC. OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im-•
prove for purpose of sale.). RES IND CON PB Other
INDUSTRIAL WASTE INTER, 30.000 I.as owner of the property.am exclusively contractingwith
0 0 0 0 ❑ °.
licensed contractors to construct the project(Sec.7(244,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 contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft 10.00 •
the Contractor's License Law. / TRACT NO. - PARCEL NO.
0 I am exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 6.00 •
reason
Owner DateWATER SYSTEM 5.00
- - - ACC.DATEACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
•
I hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified t
' copy thereof(Sec.3800,Lab.C.)-ter y�
0 Policy No./,4 Company G� 7,r�. i s, - - - -
, 0 Certified copy is hereby furnishe . • - - • FIRE SPRINK ENERGY T-24
Z z WCertified copy is filed with the city ins ection division. +
- C9 APplic•1)tt . _ a - .,- MISC.- REFER TO ORD. v 0 N 0 Y❑ NEL
CC
E2 CERTIFICATE OF EXEMPTION FROM WORKERS', PERMIT ISSUANCE 10.00 FLoo0 ZONE A.L.U.C.
Lli ? °aly COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
D
0 (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N
hundred dollars($100)or less.)
0 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
61. 1- mit,is issued.I shall not employ any person in any manner so as to
o
() bexntne subject to the Workers'Compensation Laws of California. BUILDING s
aj tilde 'Applicant ALTER OR ADD TO MECH. 5.00
>-. co' NOTICE TO APPLICANT:If.after making this Certificate of Es-
1.... Z eruption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code,you must forthwith comply with - FEE
C3 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10 0C.F.M.) 4.00 •
CONSTRUCTION LENDING AGENCY AER HANDLING UNIT(OVER 10,000C-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 of the work for which this permit is issued(Sec. MICROFILM
3097,Civ_C,). ., a / HEATING UNIT(TO 100,000 B.T.U.} 8.00
Lenders Name t
Lender's Address ELECTRIC ,
HEATING UNIT(OVER 100,0009.T.U.)9.50
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 COMP(3 H.P.or 100,000 B.T,U.) S.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100.000 BTUI SEE FEE SCH. MECHANICAL
above•mentioned 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
id,may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
granting of this permit. - MECH.CONY. LIC.NO. MECH. -
': /• ` l .I I".w t TOTAL .� TOTALSign �� pp scant Fl"r�,S �atc
INSPECTOR COPY