C 8166 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BID LDING PROJECT I DENTI FICATIO PERMIT NUMBER
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AUAPPLICATION & PERM ECg 166
BUILDING-ELECTRICAL-PLUMBING- HANICAL
�. OwNER's PLAN CH CK VALIDATION
E
7ZS/ Q`TY• ELECTRIC PERMIT FEE sa `a ()
O PHONE / II3 I' V/TZ-_,(`
CNAME ONTRACTOR UTLETS-SWITCHES-RECEP 10.00/1.00 _
LtC.NO. LIGHTING FIXTURES 10.00/9.00 � 3/f%S
ADDRESS ORS PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARRCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
O
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
too TOSS ENG. PERMIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 -
APPLICANT'S
ADDREas MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
Q D3�
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 V/�L7 O
< u I hereby affirm that 1 am licensed under provisions of Chapter 9 6/
< a (commencing with Section 7000)of Division 3 of the Business and IS CE DATE
UAN
H 7 i Professions Code,and my license is in full force and effect. ❑ ❑BLDG. ELECT. PLG. MECH.
1:1 11 i T W License Class Lie.Number
Date Contractor
u s J BUILDING PERMIT
a Ir,w OWNER-BUILDER DECLARATION INFORMATION
X ;e m 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
w O a Law for the following reason.(Sec.7031.5,Businessand Professions VALUATION S/FT.
E - m J PERMIT ISSUANCE 10.00 �t�
Code:Any city or county which requires a permit to construct alter, /T
Q¢G improve,demolish,or repair any strucf are,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
a E O LL requires the applicant for such permit to file a signed statement that TOTAL �xlIp pp PE MIT TO,,
t•m m be is licensed Pursuant to the provisions of the Contractor's License MkOa,(J2 FY•� 1
Z rt Law(Chapter 9(commencingwith Section 7000)of Division 3 of the O1f
i O Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
M F the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYEE CONSTR.
y Tom - by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00 City
of
C pe)'fln0
of not more than five hundred dollars($500),):
❑ I,as owner of the property,or my employees with wagesas 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
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 so.FT.FLOOR AREA TOTAL ACREAGE
himself Or Through his own employees,provided that such such
we-
mentsarenotintendedorofferedforsale,If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES IND CON PB Omar
11 . .
1,as owner of the property,am exclusively contracting with D 0 ❑ 11 ❑
licensed contractors,to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORSPARCEL NO.
and Professions Code:The Contractor's License Law does 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 coNractol(s)licensed pursuant t0 SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO, PARCEL NO.
❑ I am - mpt undtr Sec B,&P.C.for this
eason WATER HEATER W/VENT 6.00
\ r
Owner Dat WATER SYSTEM 5.00
ACC,DATE ACC.FILE NO.
WORKERS' OMPIi KATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm Ilial I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified I ZONING ENG.SITE NO.
copy Ihereof(See.3600,Lab.C.L
Policy No. Company
0 ❑ Certified copy is hereby furnished. - FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is tiled with the city inspection division.
FO Applicant MISC.- REFER TO ORD. Y � NY N�,
29 CERTIFICATE OF EXEMPTION FROM WORKS RS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
Lu > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
0-Z (This section need not be completed if the permit is for one TOTAL Y Q• N❑ Y❑ NE]
hundred dollars IS 100)or less.)
0 O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
U. F mil is issued, I shall not employ any person in any manner so as to
0 w become subject to the Workers'Compensation Laws of California.
Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
Is.n C/
} rNOTICE.TO APPLICANT: If,after making this Certificate Of Ex-
H Z emption,you should became 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 permit shall be deemed revoked. AIR HANDLING UNIT ITO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10010C.F.M.) 6.00 SEISMIC FEE Z0
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
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lenders Name HEATING UN IT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
1 certify 0sm I have read this application and some that the above VENTILATION FAN (SINGLE) 4.00
information n correct 1 agree tog to b with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COUP(3 H.P.Or 100,0008.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP lover 100,000 BTU)SEE FEE SCH. MECHANICAL
(We),agree to save, indemnify and kee harmless flit City of MISC.- REFER TO ORD.
Cupertino agar liabilities,judgme s an xpenses which CONST.TAX
may in a accrue against W C' in c quence of the PERMIT ISSUANCE 10.00
rant) - permit' MECH.CONT. LIC.NO. MECH.
J4 TOTAL TOTAL
I tureof Applia [ o actor Date
OFFICE COPY