C8154 ' APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BU LDI NG PROJE NTI FICATION PER IT IN MBER
BUILDING „ APPLICA N &.PERMIT a/�t
ADDRESS ,sir±'.". XKe A
I _ r , I BUILDING-ELECTRICAL-PLUMBING -MECHANICAL e
0 N R'S - LAN CHECK VA LIDATION
NAME QTV. ELECTRIC PERMIT FEE
NAME
• , 1 �C GC_ N:EU _ C Z
R cTORsfllI-7UTLETS-SWITCHES-RECEP 10.00/1.00
uc.No. LIGHTING FIXTURES 10.00/1.00 - -
'°NIRA T s �l' n - PPLIANCES-RESIDENTIAL 4.00
ADDRESS 11 3' y 5(.1• SCI frt S TQ IQ
��� PHON Iq p PANELS 10.00 �� � DATE OF APPLICATION
't OgcHlre T - PANELS(OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
EN!___�R LIa NO, SIGNS TRANS. 3.00 t8•
ARCH. RENG. PERMIT VALIDATION
C1Cc1rx1 i� ve
ADDRESS SPECIALCIRCUIT 5.00
o�tca
EMP.ME ER OR POLE INS. 20:00 v r' Q/0APPLICANT'S r
?
ADDRESS � MOTORS SEE FEE SCH.
-� \ r C� CC G SERVICE CHANGE - 20.00
.woo
LICENSED CONT'FACTORS DECLARATION TEMP.POLE 30.00 a
G u u I hereby affirm that I an licensed under provisions of Chapter 9 ISSUANCE DATE
w a w (Commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT, PLG. MECH.
F wD z Professions Code,and my license is in full force and effect.
z O w - License Clan •< Lic.Number :' ` I 1 E] �-
Q z H an Datc Contract., —
Q BUILDING PERMIT
¢ ¢o a u
OWNER-BUILDER DECLARATION _ INFORMATION
F:
3 LL N I hereby that I an.exempt from the Contractor's License MISC.- REFER TO ORD VALUATION S/FT.
F LL O J Law for the Ullowing reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 1L100 G „�
my Code:Any city or county which requires a permit to construct,alter, ,{e
¢ a ¢ 0 I improve,demolish,or repair any structure prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. �7 "iv
-O u requires the applicant for such Permit to file a signed statement that TOTAL / PERMIT TO
n an m. lie is licensed pursuant to the provisions of the Contractors License J
F z a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe S/N VS TRr-yiC
E O Business and Professions Code)or that he is exempt therefrom and QTV. PLUMBING PERMIT FEE
Bi H m life basis for the alleged exemption.Any violation of Section 7031.$ STORIES TYPE CONSTR.
03 _ by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA) 500
of not more than five hundred dollars SSW).): . .
IT
❑ I,as owner of the property,or my employeesiwith wages as BACK F LOW PROTECT. DEV ICE 4.00 OCCGROUPRES.UNITS
their Sole compensation,will do the work,and the structure is nor a'
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 po '
Code:The Contractor's License Law does not apply to an owner of h - 3 �.
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 a -SO.FT.FLOOR AREA TOTAL ACREAGE
•
himselforthrough his ownemployees,fors providedthatsuch imProre- r d�
mmselfo thr intendeughhis or offered ees,provided
that sthe building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00 is /
or improvement is sold within one year of completion, . -OVER 4 (EA.) 2.00 the owner- GAS-EASYSTEM
builder will have the burden of proving that Be did not build or im- BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,as owner of the property,am exclusively contracting with Q ❑ ❑ ❑ ❑
licensed contracture to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
Contracts for such projects with a ttrmmcmNs)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00
TRACT NO. PARCEL NO.
❑ lam exemptuniderSec.-.bcorl,_foruds WATER HEATERW/VENT 6.00
on
Owner Dale WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPFNSA'I'ION DFCLARA'TION WATER TREATING EQUIP. 5.00
I bcreby infirm Nal I hove a certificate of consent to s'clf-insuro,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO. '
3 " copy Ihercof(Scc.3800,LhCA l I
Policy No. Conn pany �G F.t '� '
❑ Cmf - Ca PY n' Iereby fu tonh'd. '�S FIRE SPRINK ENERGY T 2
tcl
Fp Applicant tint cop - t�ryl� tl 'iIY,I,C 'Lcn MISC.- ? REFER TO ORD. Y ❑ NE] YQ NE]
CC CERTIFICATHO1r EXEMPTION FROM dWORKERS' 'PERMIT ISSUANCE 1,0-00 � �'n/ PLOODZONE A.L.UC.
W COMPIENSWCN IN'SURANCF PLG.CONTR. LIC.NO. PLG. 7o Y Y❑ N❑ V E] N❑
CL 0 IT his section need not be completed if line permit is for one TOTAL
hundred dollars 1$100)or Ices)
U O I certify that in the perfornnunee of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY-
LL
UMMAflW
LL T-v mit is issued.I shall not employ any person in any manner so as to '
O become subject to the Workers'Compensm ion Laws of California.
a
Dam Applicant BUILDING 1 [;
} to NOTICE'10 APPLICANT: IC after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00s-
F Z emplion,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 provisions or this peril shall be deemed revoked. k AIR HANDLING UNIT(TO 10=11F.M.) 4.00
CONSTRUCTION LENDING AGENCY 'AIR HANDLING UNIT(OVER 10JWC.EM.) 6.00 _. SEISMIC.FEE�' � 36
, �
I hereby affirm that there is a construction lendingl "7 l _
agency fori G, •� EXHAUST HOOD(WITH DUCT) 5.00 . "' 'L
the performance of the work for which this permit is issued(Sec. - _ MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name C.._I _ K-
Lender's Addrlis�:.1aIL,� �Ft�P��v 5� HEATING UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC (Z
I Certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 1
inn Durationis correct. I agree to comply'with all city and cowvy PLUMBING
ordinances and slate laws relating m building construction, and BOILER-COMPOH.P.or100,000B.T.U.) 6.00 70 ---
anave-hereby authorize representatives for i ins of ections city to enter upon the BOILER-COMP lover 100,000 BTU)SEE FEE SCH. MECHANICAtL4 La-;I
above-ntenlinncA properly for inspection purposes.
'(We) agree to save, indcnaify and keep harmless the City of MISC.- p. REFER TO ORD. � i --'
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX A'v
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 y`r`
gmnlingof this permit. MECH.CONT. LIC.NO. MECH.
.r TOTAL 35 TOTAL �d. 3E
$Igna[ure of pp aanl/ quruclor Ua[e %�
INSPECTOR COPY
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