8263 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL,KOINT"PEN ONLY
BU PERMIT NUMBERBUILDING LDING PROJECT APPLICATION & PERMIT
ADDRESS
AOOREss
BUILDING — ELECTRICAL—PLUMBING—MECHANICAL 8263
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
N+442 n'I Tons I
CONTRACTOR'S 'Y
NAME ", I I OUTLETS-SWITCHES-RECEP 10.00/1.00 -�
�' � uc:No. 1 'LI GHTING F IXTURES• '1 10.00/1A0 . "
r.0 TRA, OR�/��YR ,I� C PPLI ANCES'-RESIDENTIAL 4.00, - I
ADDREA5 W�IV . 13 rv) `JTZ I I
jI \l PRONEI PANELS 10.00 ' DATE OF APPLICATIONI
• O. ARp E PLAN CHECK FEE P.C.NO.
/,/• OR PANELS (OVER 200 AMP) 20.OQ:
ENGINEER
LIC NO, SIGNS TRANS. 3.00
'f AARCH, RDDRESS ENG SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
q•
APPLICANT ZIP TEMP.METER OR POLE INS. 20.00
SCH.
ADDRESS MOTORS SEE FEE
CH.
SERVICE CHANGE 20.00 (� C
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a v I hereby aftlrm that I'am licensed under provisions of Chapter 9 ISSUANCE DATE
wG wIcommrOCing with Section 70007 of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F D z Professions Code nit cnse is in full fo •aBt) ffucl ❑ El z o y - License Chess l m Number
o w oe Date_��15 Contra tor%
�r
a m s iw i;a.s- h-•-Bm. . s s a . :.-..y..-. _ . r _ y BUILDING PERMIT
owM1l
I•-¢ BIw .aAUILInIRDI CLnRATIov' -' -- ' - INFORMATION
aa MISC.— !REFER TO ORD
w o3 LL H 1 hereby aflinn that I am exempt from t¢Con[ractor License VALUATION
.F LLo¢ Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00
Code.Any city or county which requiresa punnit to construct,alter,
IS , ¢ o improve,demolish.or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
0 S, requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
d w m Ile is licensed pursuant to the provisions of rhe Contractor's License
FZQ Law(Chapter 9(commencing with Section 7000)o f Division 3 of the
4 D Business and Professions Code)or that he is exempt therefrom andQTY. PLUMBING PERMIT FEE
I- p the basis lot the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a3w by any applicant for it permit subjects the applic:mI We civil penalty ALTER-DRAIN -WATER IEA.) 5.00
cram more than five hundred dollms(8500).1:
❑ I,as owner of the property,or my employe'with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP. RES.UNITS
their sole compensation,will do the work,and Ora structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Cod,:The ContmclorA License Law Boas not apply to 1n owBIr(it -
property wllnbuildsorimproves thercon,and whodoe,such work FIXTURES-PER TRAP 5.00 SO.FT FLOOR AREA TOTALACREAGE
•. himself or through his own employees,provided that such improve-
.,
mcnts are not intended or oHcrW1 for sale.It,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6:00
err improv,nhant is sold within one year W completion, the owner. GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the hurden of proving that he did not build or int- - - . l
[ RES IND CON Other
prove for purpose of gale.), ,
PB
❑ I,as owner of the property,ton exchlsively contracting with INDUSTRIAL WASTE INTER. 30:00 El El ' ❑ .�
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. ro
and Professions Code rite C.B raetoh License Law does nor apply
ro an owner of property who builds or improves thereon,and.Who LAWN SPRINKLERS-OVER 5(EA.) -.1:00 _ k
contracts for such projects with a contractors)licensed pursuant to
rhe Convenor's License Law.
SEWER-SANITARY-STORM EA.200ft/10:00 TRACT NO, PARCEL NO. 1
❑ I am exempt Under Set.—,B&P.C.In,this WATER HEATER W/VENT 6:00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC FILE No.
WORK ERS'COMPI:NSA1'ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to set6insure, - i ZONING. ENG.SITE NO.
or a cettifrcate.of Workers'Co...pco.ion Insurance,or a ceni(ieJ q
copy thereof(Sec 38 alb.C.)/� �. IA
policy Nsr.1�SL10 y If forms cL4w-�..M�)dQ:a+.�.
Q ❑ C I m copy Ia rnrcby(amts d \ t FIRE SPRINK ENERGY T2
z Z q/e;ep1`f.�- o y Is f11, LLh th arc ry inspection division -
' O' • 'Apphcifft�"G QA4�Gl h:�'\(=' 'Ir l(.� • r vtJ MISC.Cr': '.i .::.y N .-.REF.,ER-TO.ORD. _ .-•Y.Q; NQ :,•Y ❑ ,N�
y CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 1000 - FLOOD ZONE A.L.U.C.
LUQ COMPENSATION INSURANCE PLG.CONTR. LIC NO. PLG. .ISj Y� NEI Y � N❑
Z (This section need not be completed if the permit is for one TOTAL t
hundred dollars IS 100)or less.) - -
U O 1 certify that in the performance of the work for which this per, OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
ED Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
.} (n NOTICE TO APPLICAN"F: Ir.after making this Certificate of lix-
r Z_ emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisionsor this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10)"C.F.NL) ,4',00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10SWC.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 1'
3097,Civ.C.1. HEATING UNIT(TO 100,000 B.T.U.) .8.00 1
Lender's Name
Lenders Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that l have read this application and state that the abuse VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with 111 city and county PLUMBING
ordinances and slat, laws relating IH building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize represenurives of this city to enter upon the BOILER-COMP IOver 100,000BTU)SEE FEESCH. MECHANICAL
ubovc-mentioned property for inspection RD,m.,
(We) agree [o save, indemnify and keep ha nn less rhe City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgarrnu, costs unit expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
gra C oI this Pcrmtl. MECH.CONT. LIC.NO. I MECH.
TOTAL TOTAL
to e u App¢an 'o roc or
,*W'' INSPECTOR COPY