5508 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —. USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
Z BUILDING—ELECTRICAL—PLUMBING—MECHANICAL 5508
�, OwrvER'S v^ 1, PLAN CHECK VALIDATION
E °4'. a Y -'4 , a ay� a'c
OT:Y.}, . .,EL'ECTRIC'PERMIT .,.f ':�",iv`5`Y
T AC ORS
rd
�/f u M GUdl ❑ OUTLETS•SWITCHES-RECEP 5.00/100
yx.-' - sec.No. 19946 LIGHTING FIXTURES 5.00/1.00
95 or
r.ONTRACTGR'S Nth PPLIANCES-RESIDENTIAL 4.00 '
aD0REs5 JJ p
Renstorff Suite G. PRONE 415-961— PANELS 5.00 DATE OF APPLICATION
\ ARCHITECT PLAN CHECK FEE' P.C.NO. .
OR 7161 SIGNS 6.00
ENGINEER '
LIC.No. SIGNS TRANS. 3.00
ARC" OR
ENG' ' SPECIALCIRCUIT '5.00 PERMIT VALIDATION
zlv TEMP.METER OR POLE INS. 15.00
APPLICANT -
ADDRESS MOTORS SEE FEE SCH.
I SERVICE CHANGE 10.000.00
F o
LICENSEDCONTRACTORS DECLARATION '
a u r. I hereby affirm that I am licensed under provisions of Chapter 9
w a (commencing with Section 7000)of Division 3 of the Business and - ISSUANCE GATE
F w Professions Code�a0 license is in tall(ars'q�{y1,pfl,�uk B D ELECT. PLG. MECH.,
2 0,.r'— License Class L-1�Lic.Nwnber-451_ LQ.i2.4 -
0 n—0 Datc Contractor
_ w
¢ w a OWNIiN-N UILUF:R DECLARATION - - - BUILDING PERMIT
' Oe. v, MISC.— REFER TO ORD +>n INFORM TION -
w ; w w I hereby affirm that I am exempt from the Contractor s License
FU. Law 1'or the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 600 VA WATION S/FT.
va Code:Anycily orcouity which requires a permit to construct,alter,
.t' l
re aa Q improve,demolish,Dr repair any structure,prior to its issuance,also ELEC.CONTR. ELEC. V
iL m LL requires the applicant for such permit to file a signed statement that TOTAL e
w he is licensed pursuant to the provisions of the Contractor's License -PW MIT TO
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe y k, t i
i o Business and Professions Code)or that he is exempt therefrom and QTY- PLUMBING PERMIT FEE I
¢ H m ckv
the basis for the alleged exemption Any violation of Section 7031.5 „ :. 4.:kj4' °ate.. . . . x t 54" ¢'k3„ STORIES TYPE CONSTR.
by any applicant for u permit subjects the applicant loo civil penalty ALTER-GRAIN&VENT-WATER'(EA.Inq,00
of not mom than five hundred dollars(5500).):
❑ Las ompen at the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 " OCC.GROUP RES.UNITS
their sole compensation,will(S the work,and the structure is ons
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,_AREA,COND. 4.00
Code:The Contractor r improves
License Law neon not apply to an owner of
property who builds or improves(hereon,and who dues such work FIXTURES-PER TRAP 4.00 SQ FT.FLOOR AREA TOTAL ACREAGE
himself m Through his own employees,for sale.provided(hat r,t h buildve-
or nts improve m nt is old mr o in one earo If,however,)the o building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4-00
or improvement is sold within one year hacompletion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.)
builder will have the burden of proving that he did not build or im- ,1.00 ° BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 r+Es IND O - PB Other
Ell Lies owner of the properly,am exclusively contracting with _ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-I INC 5 V.B. 5.00 ASgE550R PARCELNO.
and Professions Code:I'he Contractor's License Law does not apply
to an owner of properly who builds or improves themmn,end who LAWN SPRINKLERS,-OVER 5(EA.)- 1,00 r '
contracts for such projects with a contractods)licensed pursuant to '
the Contractor's License Law. SEWER-SANITARY-STORM EA.200f1/8.00 TRACT No., PARCEL NO.
❑ Iain exempt under Sec.—,BAP.C.for this
reason WATER HEATER W/VENT 4,00
Owner Dam WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
• -WORKERS'COMPENSAIITON DECLARATION _ WgTER TREATING EQUIP. 4.00 '
I hereby affirm that 1 have a certificate ofconsent to self-insure,
or a certificate of Worked Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy lhercol'(Sce.3800,Lab,C.).11 iilI,�,,,,,,�. kk,,������yy s,
Policy No. CompanY—L.Luerty—f_ffLYI,Ia.1L
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-}4
Z 2 ❑ Certified copy,is filed with the city inspection division. MISC.- REFER TO ORD.O Applican! - Y El,- N❑ Y ❑ N❑
LU y CCRI'IItlCOI OF EXEMPTION FROM fiRS' PERMIT ISSUANCE 6.00 FLOOD ZONE a.L.u.C.
W C
� '' COMPENSATION INSURANCE
. PLG.CONTE. u0.NO.CL PLG. '
Z (This sectisectioncon need not be completed if the permit Is for ne oTOTAL Y❑ N❑ Y❑ N❑
hu ndreddollars(S 1 the less) y u;.. -
U I- 1 certify that h the temploy
performance of the wink for which this Per, „`H"' ' FEE SUMMARY
LL F mR Is Issued,I shall not employ any person in any manner u,as to QTY. V MECHgNICAL PERMIT FEE
O W becomesoldco to the Workers'Com pensation Laws of California - '" ^h
Dale Applicant - BUILDING
>_ W NOTICE IO APPLICANT:Jf,after making this Certificate of Lx ALTER OR ADD TO MECH. 4 00
2 cmption,you should become subject to the Workers'Compensation APPLIANCE - 4.00 PLAN CHECK
provisions of the'Labor Code„you must forthwith comply with FEE
U - such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10=11F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=0C.F.M.) 5.00 SEISMIC FEE
I•hereby affirm that there is a construction lending agency for - EXHAUST HOOD(WITH DUCT)” 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,CivC.). - 'HEATING UNIT(TO 100,000 B.T.U.) 4.00 ,
Lender's Name .HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
Icertify that l havercad B,isapplicationund state that the above VENTILATION FAN (SINGLE) 3.00 '
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state,laws relating to building construction, and BOILER-COMP H.P.Dr 100,000 B.T.U.) 4.00
( -hereby,authorize representatives of this city.to enter upon the ` BOILER-COMP (Over[00,000 BTU(SEE FEE�SCH. MECHANICAL.
above-mentioned properly for inspection purposes,
( (We) agree to save, indemnify and keep lmrmle;ss the City of Misc.- REFER TO ORD. r
Cupertino against liabilities,�judgments, costs and expenses which CONST.TAX '
may in any way acco ainst said City in consequence of the. PERMIT ISSUANCE - 3.00 '
granting (this i MECH.CONT. LIC.NO, ' _ MECH:-
itimorm OFA ,- /Contractor Da[e ' TOTAL n r f�TOTAL y'4§ g(i
OFFICECOPY