8567 A�PPLICARIT TO FILLAvh INWITHIN RED LINES - USE BALL POINT PEN ONLY
t; 61U LDING PROJECT IDENTIFICATI ON PERMIT NUMBER
amLOINc,. " sFt: APPLICATION & PERMIT
osd BUILDING
-ELECTRICAL-PLUMBING-MECHANICAL
8567
PLAN CHECK VALIDATION
NAME I QTY. ELECTRIC PERMIT FEE
�) ) IPHONEL,IA
CO TRACT 5. _
NAME _ -1� aOUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES.- 10.00/1.00 '
/ r:oNrRAcro 's :,ST r-15 APPLIANCES-.RESIDENTIAL 400
ADDRESS t l II U• \ , .
P ..
PANELS _ "-t' �',' , 1000 DATE OF APPLICATION
O ,^
.. PANELS.(OVER 200 AMP) -'2000 ENGINEER � '� � PLAN CHECK FEE PC NO.
r
ilo.Ivo SIGNS TR ANS, - 300
ARCH OR ENG.^ : PERMIT VALIDATION
r + aoonsss ! 2. SPECIAL CIRCUIT . 500 ,
ZIP TEMP.METER OR POLE INS. 20 00
ALIREESNTE MOTORS SEE FEE SCH. /
ADDRESS
SERVICE CHANGE 20.00 _/ks
w O o LICENSCD CON'I'RACTOIU DECLARA'T'ION TEMP.POLE 30.00
ori W I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w au (.olvenci ng with Section 7000)of Division 3 of the Business and SLOG. ELECT. PLG. MECH.
r w i Professions Core,and my license is in full force and cffcl. ❑ 1:1 El
o m - License'Class n-%=fin Lie.Number
0 z �_ow Date ��-Contractor DP
a xBUILDING PERMIT
A o
¢ 0 m a OWNER-BUILDER DECLARATION
d u INFORMATION
X g LL y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
OR Law for the following reason.(Sec.703 L5.Ifusinessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any eilyorcounty which requires a penult to construct,alter,
ELEC.CONTR. LIC.NO.
as a ¢ o improve,demolish,or repair any structure,prior m its issuame,also ELEC.
as E. o or requires the applicant for such permit to file a signed statement that - TOTAL
PER T
X m lie is licensed pursuant to the provisions of the Contractor's Liwnsc
F z aLaw(Chapter 9(commencingw'illi Section 7000)of Division 3 oftbe QTY. PLUMBING PERMIT
/}A�G
f 4 o Business and Professions Code)or that he is exempt therefrom and FEE
¢ H e the basis for the alleged exanption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i 3 ° by any applicant for a permit subjects the applicant to a civil penalty
.foot mom than five hundred do][..(S500).): ALTER-DRAIN&VENT-WATER (EA.) 5.00 i
❑ E as..e if the property-or my employeesWith wages as . . .
Units Ic ComPen non wqI do tireork� and the ,rudun is nBACK FLOW PROTECT.DEVICE 4
ot 00 i;; OCC. RES.UNITS
intended or offend for ISed 7044 tlu:nes nil Professions DRAINS-FLOOR,ROOF,AREA,COND, 5 00 - _ -
Code The Contract its LuenseL I does not apply loran owner of. �l
u.,v..
prop rty who builds or Improve theinand who do"such wok FIXTURES'-PER TRAP _ 5.00 SO.FT.FLOOR A.R.EA TOTAL ACREAGE 1�1
himself or through his own employers Pro
ded that such improve.
an Get mas dedoofftred4orside.1L however,the buildm
g GAS-EA.SYSTEM-1INC.4OUTLETS- 6.00
or unprovanenl is sold within ohe year of completion the owner. )
GAS,;,EA.SYSTEM-OVER 4 (EA.) 2.00 - I�
builder will have the burden ofproving that he did not build oat
r t - BUILDING USE '
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON P8 Omer•-, )'
O 1,as owner of the property,am'exclusively contacting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the,project(Sec.7044;,:R'usiness LAWN SPR INKLERS-1INC 5 V.B. 6.00 .t, ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Caw docs Got'ipPly '
to an owner of property who builds or improves thereon.arid who LAWN.SPRINKLERS'-OVER 5(EA.) 1.00
contracts for such projects with a contractons)Iliansed Purstmnl to -the Cmr ranor's License L:Iw, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,tl.&P.C.for❑us
reason WATER HEATER W/VENT 6.00
WATER SYSTEM 5.00 ACC.DATE AOC.FILE NO.
W'ORKERS'COMPENSA'r10N DECLARATION WATER TREATING EQUIP. 5.00
iTh achy utnof, that I have R c,"Rific,t6 cit:consent to scpGinsun,
erla certificate of Workers Compensation Insuiaiice,or a certified ZONING ENG.SITE NO.
Copy Thereoft8ec.3800,1 b.C.). '"17 t�t71
)ohcyN 'PA 3 �. Cr
C) ❑ CL R stied Copy is lie by furnished, FIRE SPgINK EN[RGV T-10
_ •z
Certified co�iy is filed with the taIy. inspection division.
'Fz O'er`<7 pbcani '4t.yil� SSE t4b a`�"�a�'^F t-l-T-i - MISC. Vit._;: . ; _. REFER TO ORD. . 'v❑ N❑ v ❑ N❑
U. tos CLRTIFICArI 01 EXEMI'1 ION FROM WORKERS' PERMIT ISSUANCE 'i 10.00 FLOOD ZONE A1.UC.
W�-"' -/�'`�-� COUPEN. ATION INSURANCE PLG.CONTE. LIC.NO. PLG.
CL
❑ N
❑ ❑ ❑
0 ? OTliis section cud not be completd eif tlieL is Pcnnifor one TOTAL Y N Y
Z) Z hu ndredd61lNr051001orless.) -Af -
j -
U O ,-1 certify dill in the performanceof the work for which this per, QTY. MECHANICAL PERMIT FEE FEE SUMMARY -
EL} mit is•issued,'Ishal) not employ any person in any manner so as to
0W bet! tie•subjcd to i lie Worker,'Cnm pebsa(iini L-awsof California.
tD Date Applicant - BUILDING
} SO NOTICE. '1'O APPLICANT': If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
F Z Cntption,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
Provisions of the Labor Code, you must hirthwith comply with
such provisions or this permit shall be deemed revoked.,_ AIR HANDLING UNIT(TO 10=C.F.NL1 14.00 FEE
A CONS'IRUM ION LENDING AGBNCY'.�'5;1. AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a tonstrictiom leading 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.) L8'00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Addict s___ HEATING _ ELECTRIC (,
I Certity that l[love read.tlns application andsvde that the Stove ' .`-• VENTILATION FAN (SINGLE) ' 4.00
information is correct. with all city
I agree to comply and county - PLUMBING
ordinances and state laws relatmg'to budding construcNom'and BOILER-CON?(3 H.P.or 100,0008.T,U.1 600
hereby authorize roperty for
of ory city to nl L upon the BOILER-COMP (Over 100,000 BTU)SEE FEESCH MECHANICAL
abo c mLntioned property(or inspu Yon purposes '- n PV
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. -
Cupertino against liabilities,judgments, costs andexpenses which PERMIT ISSUANCE 1 .00 CONST.TAX
may in any way accrue against said City in cons..Renee of the J
gramingoflhis permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signature ApP / ontrue .Date 4i
INSPECTOR COPY
" I