8576 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
/ ADDRESS 1O C 7 6 alI �-
_)L -� � BUILDING - ELECTRICAL-PLUMBING-MECHANICAL Q J
OWNER'S ;T PLAN CHECK VALIDATION
t NAME � ,22•%//QTV. ELECTRIC PERMIT FEE
YA v"oNE '1
NA.E croRs OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME _ _
Ilalltr /en IL I1 V Lt..No.iq�e_�n LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
aoDRE�s1s (' S -} Y'
/ , ! / 1, f l/�t' }�4 ONE Jr. ,.a- f/7im PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.08 PLAN CHECK FEE - P.C.NO.
OR
ENGINEER
LIC No. SIGNS TRANS. 3.00
moo ESS E "G SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
zIv TEMP.METER OR POLE INS. 20.00
ADRES Nrs
ADDDRESS MOTORS SEE FEE SCH. OL / r
F/1J
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE d 30.00
is u I hereby affirm Iflat I am licensed under provisions of Chaplet 9 ISSUANCE DATE
(Commencing will,Section 7000)of Division 3 of the Business and SLOG. ELECT. PLG. MECH.
FD i Professions Code,and my license is in full force and effect
z o m - License Class G ":�Lic.Number14 �r't�_ El 2 ❑
O F Date_p. .^^r ConiractorF , 'S-/• }
a y E r BUILDING PERMIT
Be w4 OWNER-BUILDER DECLARATION INFORMATION ,
E 0 W,U REFER TO ORD
X ; y I hereby affirm that 1 am exempt from lite Contractor's License MISC.-
H .. o¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE +n nO W VALUATION g/FT.
Code:Any city or county which requires a permit to construct,alter,
Q2improve,demolish,or repair any structure.prior to its issuance,also ELEC CONTR. UC.N0. ELEC. /V.'s
Be requires the applicant for such permit 10 file u signed statement that U TOTAL PERMIT TO
wca m" he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)of Division 3 oflhe
< Business and Professions Code)or that he is exempt therefrom and (ITV. PLUMBING PERMIT FEE
r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i ;`0 by any applicant for a permit subjects the applicant to u civil pennity ALTER-DRAIN -WATER (EA.) ,p0
of not more than five hundred dollars(8500).): /
❑ 1,as owner of lite property,or my employees with wages as BACK F LOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
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
properly who builds or Improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
. clients re not hrough
ownemployees,rsck,I tdh.vvevsuch imildinrosGAS-EA.SYSTEM-1 6.00
meats are not Inmn did or offered for sale.It,howcat s the building
or improvement is sold within one year of completion.the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im RES IND CON PB Omer
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 -
❑ 1,as owner of the property,am exclusively contracting will, ❑ ❑ ❑ ❑ ❑
licensed contractors Io construct the project (Sec. 7044,BIISIOCSS LAWN$P191NKLERS- 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 It. LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a cuntrector(s)licensed pursuant to $EWER-SAN ITAR V-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Co nuacm,s License Law.
❑ tum exempt under Sec. ,B.&P.C.tirr this WATER HEATER W/VENT 6.00
son
Owner Dice WATER SYSTEM 5.00
ACC.DATE ACG FILE NO.
W'ORKERS'COMPI�NSAnON DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconsent to set Ginsure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.0.).
Policy No. Company
❑ Certified ropy is hereby furnished. FIRESPRINK ENERGY D24
z Z Certified opy is filed with the city inspection division.
O Ap6CB �/.r� +./+-��,��,� .,;� MIS[.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
fl' N CERTIPIVA1 E OF I XEMPTH`N FROM WO�uv`HKERS' PERMIT ISSUANCE 10 DO V3; FLOODZONE aL.uc.
W COh1PfNSA1'ION INSURANCE PLG.CONTR. LIC.NO. PLG. W
d O (This section need not be completed if the permit is for one TOTAL /( Y❑ N❑ Y❑ N❑
Z bun died dollars IS 100)or less.)
L) O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
W F mit is issued,I shall not employ any person in any manner so us to
Q w become subject to thse WorkerContpensat ion Laws of Cahlor ul. BUILDING
n Date Applicant ALTER OR ADD TO MECH. 5.00
} to NOI'ICIi TO APPLICAN'P: If,after making this Certificate of Iix-
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of lite 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
CONST RUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=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 3097,performance of the work for which this permit is issued(See. MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,0008.T.U.)9.50 wCIL
Leme address ELECTRIC
I certify llwt I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county
•- ordinances and state 1a Ws relating to building construction, and BOILER-COMM H.P.or 100,000 B.T.U.) 6.00 PLUMBING /O
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indenmify and keep Imruless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against uiJ City in consequence of the PERMIT ISSUANCE 10.00
allflR of this per Il..�1 MECH.CONT. LIC.NO. MECH. !'
,.�1, . Inrrn :/7/Y� TOTAL TOTAL a2V
are 6f Apphcanl/GonlraUnr Du[e
INSPECTOR COPY