C8482 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LD ING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT r
J ao-I BUILDING - ELECTRICAL-PLUMBING-MECHANICAL B4-82
r OWNER ' PLAN CHECK VALIDATION
NAME .7S2- QTY. ELECTRIC PERMIT FEE
'x
Home rolls CO
UTLETS-SWITCHES-RECEP 10 .00
uc.ND. LIGHTING FIXTURES 10 /1.00
CA-
r ADDRESS 4/.�y.�/'y �j��j PPLIANCES-RESIDENTIAL 4.00
\ PRONE 11 V O�I� PANELS IO.00 GATE OF APPLICATION
ARINFILTMOR B PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER "4��V�
} LIC.NO, SIGNS TRANS. 3.00
ADDRESS ENc, SPECIAL CIRCUIT 5.00 / PERMIT VALIDATION
I ZIP EMP. METER OR POLE INS. 20.00
Avvucnrvr's
ADDRESS MOTORS SEE FEE SCH.
I
SERVICE CHANGE 20.00
ro o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
La (commencing with Section 7000)of Division 3 of the Business and
8 D ELEG PLG. M C
y i Pro Cessions'Codtmy license is in full to
-•un u
z 0 w - License Cl Lie NI
Number' ,-"a1.y---
9 w r Date Contractor-���,y{{1�l(J f \
ee wa R-BUILDER DECL)RATIONe BYN INFORMATION
e' MISC.- REFER TO ORD
E
;t H I f hereby affirm ing I am exempt from the Contractor's VALUATION
F LLOj Law for the following reason.(Sec.703L5,liusinessund Professions PERMIT ISSUANCE $/FT.
m s Code:Any city or county which requiresa permit to construct,alter, _
sr 00 improve,demolish.or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO, ELEC.
Le
0 S, requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
A w m m he is licensed pursuant to the provisions of the Contractor's License
H z a
Low(Chapter 9(commencing with Section.7000)of Division 3ofthe
4 0 Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE /
/11--
It 1- the basis for the alleged exemption.Anv violation of Section 7031.5 STORIES N R.
d 3 � hYany
nure than
fora hundred
solids the0R.):applicant toaavd penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00 � �.� L_O(-4
of not more tllan five hundred JDlluzs(SSOOj.I: y
❑ I,as owner at the property,or my,and yes with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC,�RoyP =sul+�5
their sole compensation,will er the work,and the, with re is not 'I7_A( f!//G�
intended or offered for sale (Sea 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply loan owner of -
• property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.Fr.FLOOR A EA Torg CELE
himself or through his own employees,provided that improve-
.cuts am not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.40UTLETS 6,00
or improvement is sold within one year of completion,the owner
builder will have the burden of proving that be did not build or in,- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of sale,). RE IND CON PB Other
❑ I,as owner of the property,um exclusively contracting with INDUSTRIAL.WASTE INTER. 30.00 ❑ ❑ ❑ 0
licensed contractors to construct the project(Sec. 7044, Business LAWN SPRINKLERS- 1 INC.5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:'fhe Contractor's License Law does not apply '
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
ontructs for such projects with a contmetor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I and exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dale WATER SYSTEM- 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of conscm to sel Ginsure.
or a certificate of Workers'Compensation Insurance,ora cer ed / ZONING ENG.SITE NO.
copytlmr• 3 0 IL1ab�.C.). a
POIICy No�� 6y /
Q �p� Cert 1 c n Ic filed
y furnish he ! FIRE SPRINK ENERGY L]4
Z Z 7LT Certified copy is tiled with Um city inspection divisum MISC.- PREFER TO ORD. N� ' �
O Applicant y v N
N CE ' PERMIT ISSUANCE 10.
; )Ph ;h1 I 'R. )RKERS' 71FLOOD ZONE A.L.U.C.
W > COh11'fiSA'1']ON INSURANCE PLG.CONTR. LIC.NO. PLG. ❑ ❑ ❑ ❑
CL 0 (This section need not be completed if the permit is for one TOTAL Y N Y N
hlmdreddollars 151001,o Iess.l
U O
I cenily that in the performance o1'the work for which III is per OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL {- mit is issued, I shall not employ any person in any manner st as to
O W ,bccohe
Late, uhje to the Workcrs Compensation sof C1 .al'fornia.
} A ICnNT'nl f, .r x- ALTER OR ADD TO MECH. 5.00 BUILDING
F 2 enlption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
Provisions of the Labor Code, you must I'orlhwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.NL) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING 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 performance of the work for which this permit is issued(Sec. - MICROFILM
3097,Civ.CJ, HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 L�
Lender's Address ELECTRIC JJ
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. Iagree to comply with all city and county PLUMBING
ordinances and slate lows relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives forms of this city to enter upon the aboveBOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
hereby
outioned property tativsp of this
purposes.
(We) agree lO save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,-judgments, costs and expenses which PERMIT ISSUANCE 10 CONST.TAX
may in any way accrue against said City in consequence of the
gr sting of this permit. MECH.CONT. LIC.NO. MECH.
TOTAL i TOTAL
g COn v
INSPECTOR COPY