C8488 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
'• BUI LD1 NGPROJECT I DENTI FICATION PERMI NUMBER
BUIEDINC APPLICATION & PERMIT
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•�v�PCO / SLn�IY/ L(, D✓ BUILDING - ELECTRICAL-PLUMBING-MECHANICAL (l`'JJ'
OWNER'S
PLAN CHECK VALIDATION
NAMpE
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41°IV ELECTRIC PERMIT FEESW_P1APJ vnorvE252 - 24
CONTRACTORS
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NAME rl UTLETS-SWITCHES-RECEP
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LC.No. / /o'� LIGHTING FIXTURES
ONTRE CTORs PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
T erRicmEER "7cY}�G✓ G.r+}+��c�o✓ PANELS (OVER 200 AMP) 20.00
IG nCNo. SIGNS TRANS. 3.00 n
ADDRESS ervc. f J SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
33fS r3�/ wfl�aha nP� EMP.METER OR POLE INS. 20.00
APPLICANT s
ADDRESS PPLICA 'LO(e(�5 5r"•-'y,L^' Q✓, MOTORS - SEE FEE SCH.
w+1H SERVICE CHANGE 20.00 / 0
w
00 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
O i., I hereby affirm that 1 am licensed under provisions of Chapter 9
H Z w ISSUANCE DATE
a a (commencing with Section 7000)of Division 3 of the Business and BL ELECT. PLC. MECH.
Professions Code,:rod my license is in full force and effect - / ❑ ❑
p 0 as o License Class (:f=r r IJeIT Number�r_ 0-f El
y E w D:dc�I Contractor__1'
a m E
I1: ¢ w a OWNER-BUILDER DECLARATION BUILDING PERMIT
INFORMATION
X 3: n a- 1 hereby affirm that I am exempt from the Comm<mr's License MISC.- REFER TO ORD
u D j
Law for the following reason.(Sea 7031.5.Business and I'ro fessions VALUATION $/FT.
r - PERMIT ISSUANCE
w� Code Any cityorcounty which requires a permit to construct,after, ��0 /t
a,a p improve.derrI0I1Sh,Of repair any StNCtIrR,prior to its ISSIIaoce,also ELEC.CONTR.
ii: LL requires the applicant for such permit to file a signed statement that TOTAL
w he is licensed pursuant to the provisions of the Contractor's License —' PERMIT TO
r a
Low(Chapter 9(commencing with Section 7000)of Division 3 of the / r
io Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE s
M H m the basis for the alleged exemption.Any violation of Section 7031.5 i 1 STOPIES TYPE CONSTR.
a ; -- by any applicant in,.perm it subjects the applicant to a civil penalty ALTER-DRAIN IEA.) W
bf not more than five hundred dollars(SS00).):
❑ Las owner at the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 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. 5.00 R— /
Code:The Contractor's Licenu Law does not apply to an owner of
property who builds or improves thereon,and who does such work Z FIXTURES-PER TRAP —SO.FT FLOOR AREA roraE ACREAGE
`• himself or through his own employees,provided that such improve-
ments are not intended oroffered for sale,If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- J S0
Rudder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OV ER 4 IEA.) 2.00 BUILDING USE
_ prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 Rs IND CON PB Otto.,
❑ 1,as owner of the property,am exclusively contracting with . .
, ❑ ❑ ❑ ❑
licensed contractors to construct the project(See. 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:'I'lie Contractor's License Law dour not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 f—.
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARC LNO.
❑ [am exempt under Sec..,B.&P.c.for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO,
WORKS RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm thin I have a certificate of cunsmR to ul6insurc. '
-y nr a certificate of Workers'Compensation Insurance,or a cervi,Pit IL ZONING ENG.SITE'NO.
/ copy thereof(Sec.3800,Lab.CJ.
Polcy No.�1 nmpany . (B2 Y
W
O ❑ CcrTii �o (s� reby furnish€
' RE SPRINK ENERGY T24
Z O� ❑ Certified copy' is file with-the cit nkspcetion division.
O Applicant- r/ A. MISC.- REFER TO ORD. Y ❑ - N❑ Y'❑ No
w CERTIFICATE OF ;R:MPTIONFROM WORKERS' PERMIT ISSUANCE #�90 FLOOD ZONE A1.U.C.
LU 7 COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d o IF[its section need not be completed if the permit is for one TOTAL V❑ N❑ Y ❑ N❑
Z hundred dollars IS 100)or le"I
U 0 1 certify that in the perfornamcc of the work fur which this per QTY. MECHANICAL PERMIT ' FEE FEE SUMMARY
LL F mit iv issued,I xlwll not employ any person in any manna su as In
O Ed beconm subject to[tic Worker Compensation LuwS of California.
D. Date Applicant ALTER OR ADD TO MECH. R nn OL BUILDING
} sn NOTICE TO APPLICANT': If,after making this Certificate of Ex-
F 2 coalition,you should become Subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with U FEE 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 IO)ODOC.F.M.) 6.00 SEISMIC FEE
1 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,Cie.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lenders Address HEATING UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 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.) 6.00 PLUMBING ) L
hereby authorize representatives ec this city to enter upon the BOILER-COMP )Over 100,000 BTU)SEE FEE SCH.
shove-mentioned property for inspection purposes. MECHANICAL
(We)'11agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORO. --
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE �"U CONST.TAX
nhay in any way accrue ogainsl -aid City in consequence of the �0
granting oft4 s pennif MECH.CONT. LIC.NO. MECH.
TOTAL / vv� TOTAL
3ignalurn o merfice [/C011tm for ale
INSPECTOR COPY