C8444 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION PERMITNUMBER
BUILDING APPLICATION & PERMIT
ADOREss I/ If Allitt"
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL ( � 444
O ry 'S
u 06
NAME 6• -PLAN CHECK VALIDATION
WOI,t'4/EJ 8.�17lJ'ia/
t-' �` GTY. ELECTRIC PERMIT FEE-
PLIENE
CONTRACTORS
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No. LIGHTING FIXTURES 10,4.0/1.
ADDRESS00 rJ'c _
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
NE55 ,
PHONE PANELS 10.00 - DATE OF APPLICATION Op
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NOy
ENGINEER
LIc.No. 9 SIGNS TRANS. 3.00
AARCIT DDRESS M. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
IO Ld, TEMP.METER OR POLE INS. 20.00
APPLICANTS
ADDRESS MOTORS SEE FEE SCH. J
no / .o. •.r.o SERVICE CHANGE 20.00
0 02 LICENSED ONTFACTORS DECLARATION TEMP.POLE 30.00 /-Y
a v E, I hereby affirm that I an licensed under provisions of Chapter 9 'sV ISSUANCE DATE
H G w (commmocing with Seelion 7000)of Division 3 ofthe Business and BLDG. ELECT. PLG. MECH.
Z H m z Professions Code,and my license is in full force and effect
o ❑ 1:1 ❑ 1:11
- License Class �-�� Lie Number
-Ua o Date Contractor
ams - BUILDING PERMIT
a OWNER-BUILDER Df?CLARATION
rz ¢o o INFORMATION
w3: a- I hereby affirm that 1 am exempt from the Comractor's License MISC.- REFER TO ORD 2
F iL0 Law or the following Reason.(Sec.7031.5,Businessund Professions PERMIT ISS ANCE 1� ; VALUATION $/FT.
y0J Code:Any city or county which requires a permit to construct,alter,
rtin a improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. y LIC.NO. ELEC.
n wO u requires the applicant for such Permit to file a signed statement thu, TOTAL Py' PERMIT TO
m he is licensed pursuant to the provisions of the Contractor%License
F z a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
Business and Professions Code)or that he is exempt therefrom and GTY. PLUMBING PERMIT FEE
o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTRI
a ; `^ by any applicant for a permit subjects the applicant ma Civil penalty
of not more Man five hundred dollars($500).): ALTER-DRAIN -WATER IEA.) 5.00 CJL
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
sole compensation,will do the work,and the Structure is not
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 p
Code:The Contractor's License Law does not apply to an owner of 'e- 3
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 590 W SO.FT.FLOOR AREA TOTAL ACREAGE
himself'or through his own employees,provided that Such improve.
ments are not intended oroffered l'or sale if,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00 rjL /�� Q
or improemacet is sold within one year of complelion-the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will Imve the burden fronting that he did nut build or ice. BUILDING USE
RES IND CON PB Other
prove l'or s purpose critic.). INDUSTRIAL WASTE INTER. 30.00
��jj 1.d as owner of the Property,he exclusively contracting with ❑ ❑ ❑ ❑ ❑
anLd Pro contractors In construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The honb Contractor's o License Law Joel not apply
to contracts
owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
the Cttsforsuchprojectswithacontractor,$)licensed Pursuam to SEWER-SANITARY-STORM EA,200ft10.00
the CDnlnClor s License Law. / TRACT N0. PARCEL N0. .
Cl lam.xCITPI Under SIC,-,B.&P.C.for this WATER HEATER W/VENT 6.00 rh -
reason
Owner Date-/,'g WATER WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'CONPF,NSA'1'ION DECLARATION
WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate et consent to self-insure.
or a certificate of Workers:Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Set.3800,Lub.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
z Z ❑ Certified copy is filed will, the city inspection division.
O Applicant MISC.11 REFER TO ORD. ( Y❑ N❑ Y ❑ N❑
CCm �4
PERMIT ISSUANCE 10ab
CC
CfiRl'IPICCOMPENSATION INSURYNCIy01:EXEMPTION FRONIORKERS' PLG.CONTR. LIC.NO. PLG. / PL000 ZONE A.LU.C.
13- 0� )This section need not be completed if the permit i5 for one TOTAL Q Y❑ NNEI [JY N
Z ❑
hundred dolWrs IS 100)ur less.)
.U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
U become subject to the Woryr,Compensation Laws of California.
Ed Darn Applicant• ALTER OR ADD TO MECH. 5.00 BUILDING - p o
} m NOTICE 'f0 APPLICANT: If,after making this Certificate of Ex- 3e's
F Z emptio t,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions nl' the Labor Code, you must forthwith comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT TO 10=C.F.M.) 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 agenev 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 CN
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 �y
Lenders Address ELECTRIC /
Icertify that,l,have read this application and slide that to above VBWTI LATI_ON FAN (SINGLE) 4.00y - CASs
infonnalino is correct.I agree to Comply with all Cil,and county PLUMBINGOZ
ordinances and state laws relating to building cunstrucfion, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 -7
hereby authorise representatives of this city to enter upon the BOILER-COMP(0ver 100000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes. ,
(We) ogre. to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses.which CONST.TAX
nmy in any way accrue against said City in€consequence of the PERMIT ISSUANCE 10.00 /U UL
gra Iingof this Pani L MECH.CONT. LIC.NO. TOTAL
3 �i TOTAL S7 7��
B n P iGr1nt t tOr ate
INSPECTOR COPY