3386 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
IDENTIFICATIONI�
:
PER U BER
9DILDING APPLICATION & PERMIT
ADDRESS
Q
UUBUILDING -ELECTRICAL-PLUMBING -MECHANICAL
$ AK V_- _ ' _ ____ --_ _ _
NAME Q . ELECTRIC PERMIT FEE PLAN CHECK VALIDATION
FcJfL
oN
sNAME
OUTLETS-SWITCHES-RECEP 5.00/1.00
Jff&e4_kAWfJWC.NO LIGHTING FIXTURES 5.00/1.00
co"AD gyrgRAcrons bOWAIAK RC 1� PPLIANCES-RESIDENTIAL 4.00
'�/ /s' / t PHONE 14 W7 PANELS 5.00 CATE OF APPLICATION
6.OD
ARCHITECT - /t] SIGNSSIGNSPLAN CHECK FEE P.C.NO.
�
OR 1Y�El
ENGINEER
uc.No. SIGNS TRANS- 3.00
ARCH.OR ENG. - PERMIT VALIDATION
ADURESs SPECIAL CIRCUIT 5.00
ZIP EMP.METER OR POLE INS. 15.00 -
ADDRESS. MOTORS SEE FEE SCH.
ADDRESS. � '
SERVICE CHANGE 10.00
wo o LICENSED CONTRACTORS DECLARATION
a o u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
2 w (commencing with Section 7000)of Division 3 of the Bll.\IIICSS and - BLDG. ELECT. PLG. MECH.
mz Professions Code,and my license is in full force and effect. -
zO,P, - License Class Lie.Number ®-
O Z F ate Conlmctor -
F N J .
¢ x s - BUILDING PERMIT
rc rt w u OWNER-BUILDER DECLARATION' - INFORMATION
wC a N 1 hereby affirm that I am exempt from the Contractors License MISC.- REFER TO ORD
3 u y p VALUATION $/FT.
F .. 0 4 Law for the following reason.(Sec.703 L5.Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to conslruer alter,
¢ ce Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- o
IF ¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
wm he is licensed pursuant to the provisions of the Contractors License
FZi Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe ,rC'j�t� SNL
- ¢ Business and Professions Code)or that he is exempt therefrom and QTY- PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONS713.
n ; m by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not mom than five hundred dollms(5500).):
❑'h as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 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. 4:00
Code: The Contractors License Law does not apply to air owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO,FT FLOOR AREA TOTAL ACREAGE
himself or Through his own employees,provided that such improve-
mentsare not intended oroffered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or improvement is sod within one year of completion, the owner- GAS-EASYSTEM-OVER 4 (EA ) 100 BUILDING USE
builder will have the burden of proving that he did . . .
not build or int- RES IND CON PB anter
prove for purpose of sale). INDUSTRIAL WASTE INTER. 20.00 El ❑ ❑ .
❑ 1,as owner of the property,ons exclusively contracting with
0 El
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:'Tlie Contractor's License Law Joe 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 transactions)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCELNO.
X ❑ 1a Icx m tuna ec B&P C.for this WATER HEATER W/VENT 4.00
rcuso
)ate��- 3, owner WATER SYSTEM 00 ACC.OATE ACC.FILE NO.
WORKERS'COMPENSArION CLARATION WATER TREATING EQUIP. 0
1 hereby affirm that 1 have a certificate ofconsent ho sal6lvsare,
/
or a cortiti"m of Workers'Co ripensation Insurance,or a ccrtfied ZONING ENG.SITE NO.
Y(f copy thereoffSec.3800,Lal,CA � � APR 11
Policy No. Company
O ❑ Ct,nined copy is hereby furnlslmd. RE SPRINK ENERGY T-24
F
% ❑ Certified copy is filed with the city inspection division.
. Q Applicant. MISC.- RA'601309M.t
Y ❑ N❑ Y ❑ NEI
rn CERTIFICATE 01'Ii XEMPTION FROM WORKERS: PERMIT ISSUANCE 6.00 -.- FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANCE PLO.CONTR. LIC.NO. PLG. QC) Y N Y NF
1 0 (This section need not be completed it the permit is for one TOTAL
Z hammed dollars IN 100)or less.)
U O I certify that in the performance of the work for which(his per= QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL ♦- mil is issued.I shall not employ any person in any manner so as to
U become subject to the Workers Conhpe isation Laws of California.
U d Date - ApplicantALTER OR ADD TO MECH. 4,00 BUILDING
} to NOTICE;TU APPLICANT': If,after making this Certifieme of Ex-
Z_ '
contrition,you should becume subject to the Workers Conhpcnsation APPLIANCE . 4.00 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.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IOAOOC.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a e,uistruction lending agency for EXHAUST HOOD(WITH DUCT)' 2.00
the performance of the work for which this permit is Issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATI NG UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Ixe&,'s Andress
1 certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 - 4w
PLUMBING
information is ernmet.I agree to comply with all city and county '
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU(SEE FEE SCH. MECHANICAL
above-mentioned property for.in,gre c tion 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_
may in any way acerve,ageinst said City in consequence of the PERMIT ISSUANCE 3.00
'mtine"I this hermit MECH.PONT.. LIC.N0. MECH. '
_ 3 G( .' TOTAL TOTAL
S- aturc of Applicant/Can actor Date
OFFICE COPY