C8152 APPLICANT TO FIILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJEA E_NTI FICATION Y PERMIT NUMBER
aDIEDING - j APPLIC N & PERMIT
aDDREss r{^
9 ^ BUILDING-ELECTRICAL-PLUMBING-MECHANICAL /�
I OWNE 5 PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
. R T G rve
NameAcrR's ter OUTLETS-SWITCHES-RECEP 10.00/1.00 r
0 LIGHTING FIXTURES 10.00/1.00
r,
ADDRESS
�I
R5 PPLIANCES-RESIDENTIAL 4.00 1
5 ( 55�'C� , I�CI
PHOrvE, I - PANELS 10.00 DATE OF APPLICATION
Ill s
AFICHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEE
J::�Cf--1� •b. C LIC.No. SIGNS TRANS. 3.00
ADDREOR SSSS ENG' SPECIAL CIRCUIT 5.00 1 PERMIT VALIDATION
n a CI�I n I TEMP.METER OR POLE INS. 20.00. j{a- ( 1
ADDRESS rs MOTORS SEE FEE SCH.
ADDRESS ^
-I4 1<. G ,� „ �„ SERVICE CHANGE 20.00
.woo LICIiNSED CONTRACTORS DECLARATION TEMP.POLE 30.00
G o U I hereby af0n» that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w z w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r D i Professions Code„3nd my license is in full force and e(ecl. _
z o m- License Class Lia Numbe, 5_I- _
o H Uare Contractor
BUILDING PERMIT
Q Yf J
iL
or w OWNER-BUILDER DECLARATION INFORMATION
w0 n F. 1 hereby affirm that I am exempt from the Contractor's License MISC.- u REFER TO ORD
VALUATION $/FT.
u, LLov, Law for the folMwingreason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 11LOOj as
Code:Any city or county which requires a permit to construct,alter,
Qimprove,demolish,or repair any structure,Prior Io its issuance,also ELEC.CONTR. LIC.NO. ELEC. �S U V�
O 2 requires the applicant for such permit to file a signed statement that TOTAL / CN PERMIT TO
a w m es he is licensed pursuant to the provisions of the Contractors License _
F z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthc N��E ,A.Aw tS
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE •Y / /'HH.
14
H $ the basis for the alleged exemption.Any violation of Section 7031.5 1 STORIES TYPQtONSTR.
by any more
liive unreddollars(SSapplicant0Luacivil penalty ALTER-DRAIN -WATER (EAJ 5.00 a ��✓ � /
of not more than five permit)dollars the .):
❑ 1,as owner of 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 -
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 yds so.FT.FLOOR AREA TOTAL ACREAGE
himselfmyof intended
his own employees,Provided that such inq.ding
hieritsmse mnhr ugh his or employees, lclLhowever,suhchuuo'e- GAS-EA.SYSTEM-11NC.4OUTLETS 6.00 4- fi�3J
or improvement is sold within one year of completion,the owner- GAS-EASVSTEM-OVER 4 (EA) 200 BUILDING USE
builder will have the burden of proving that he did not build or mr . . .
RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL W ASTE INTER. 30.00 5i .
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑
licensed contractors to Construct the project(Sec. 7044,BUSIne.. LAWN SPR IN KLE RS- 1 INC 5 V.B. 6.00 ,ASSESSORS PARCRO.
and Professions Code:The Contractor's License Law dues not apply -
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
Contracts for such projects with a contrucloos)licensed Purs'um t to SEWER-SANITARY-STORM EA.200ft/10-00
the Contmmor's Lice nse Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sea .N.&I'.C.tix this WATER HEATER W/VENT 6.00 v.:
Cason - -7.2
Owner Date k WATER SYSTEM 5.9.0 s.. ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure. ZONING
or a cerlif,ate of Workers'Compensation Insurance,or a certified ENG.SITE N0;
copy thereof(Sec.3800Lab C.). b�
1 Policy No._Co;mpanu
y
0 ❑ Certified copy is hereby furnished. FIRESPRINK ENERGYT-74
Z Z II / rtificd copy is filed with the city inspection division. MISC.- REFER TO ORD. '
O APPlicant - vPbC .r V ❑ NE] v ❑ N[]ir W. CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE _70.00 ( FLOOD ZONE' A.L.u.C.
LU > COMPENSATION INSURANCE, PLG.CONTR. LIC.N0. PLC.
CL M1(This section Reccl not be Completed if the permit Is for one TOTAL '70 Y❑ N❑ Y❑ ry❑
Z It dred dollm'($100)o.less)
U O I certify that in the Performance of the work for which this per- QTYI MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 shall not employ tory person in any nhanner so as to
0 w become subject to the Workers'Compensation Laws of California.
Q. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING s..
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
H Z eruption,you Should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with It FEE
C.1 such provisions or this permit Shull he deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M,) 4.00
CONSTRUCTION L17NDING AGENCY AIR HANDLING'UNIT(OVER 10)000QF.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency lir. EXHAUST HOOD (WITH DUCT) 5.00
the performance`of the work for which this-permit i issued(Sec. MICROFILM
3097,Civ.C.). r HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name rh` C �'� }.`
Lender's AJdre1_1- 6T- T- ' 4, HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC 13/ ;eo
I certify that l have read this application and state that lire above - VENTILATION FAN (SINGLE) 4.00 /y W
• information correct 7U
1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building c...tructinn, and BOILER-COMP(3H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon lire ,BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL 3s-
above mentioned properly for inspection purposes.
(we) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX 5
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
granting of this permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
n tv 'of Ap licant/Co actor Uale .3 W /U.1'j .r0
INSPECTOR COPY ,
III