11210 NT TO FILL IN INFORMATION 111THIN'RED LINES —..USE BALL POINT PEN ONLY
ING PROJECT IDENTIFICATION ' . PERMIT rvuMRER ••
APPLICATION & PERMIT
0�0 m�N Rd . "1121 0
BUILDING—ELECTRICAL—PLUMBING—MECHANICAL r
ov PLAN CHECK VALIDATION
Nam t p ELECTRIC PERMIT FEE 1
A. cess /e!" PHnNE. �.30/CG '1�
coNTRACToas UTLETS-SWITCHES-RECEP .10.00/1.00
NAM / yt/I/�/�
a 6(1QMCr LIc.No. 20 elLIGHTING FIXTURES 10.00/1.00
CONTRACTOR,
G �c J PPLIANCES.RESIDENTIAL 4;00'
ADDRESS sn� SfslPHONE /O S/l%� PANELS 10.00 . DATE OF APPLICATION
ARCHITECT, PANELS (OVER 200 AMPI 20.00 PLAN CHECK FEE 'P.C.NO.
OR
ENGINEER "
'
LICNO, ISIGNS
TRANS. 3.00
ARCROREND. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
°• -
21P EMP.METER OR POLE`INS. 20.00 • • I ,�",/�
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS - �^�j�N
SERVICE CHANG -.20.00
w O o .LICENSED CONTRACTORS DECLARATION /
<is I hereby affirm-that I am licensedunder provisions of Chapter 9. I��� - ISSUANCE DATE
N z w (commencing with Section 7000)of Division 3 of the Business and, 1 BLDG. ELECT. PCG. - a
F iProfe
ssions Code, my license is in full fort f . ❑0 License C sLie.NumberUIr X1 I ContractorC BUILDING PERM
a rc w � wr1eR-BUILDER DECLARATION ` INFORMATION
E:
0,LL 1 hereby affirm that 1 am exempt from the Contractor's License 'MISC.- REF TO ORD
y p 0—_ VALUATION
F_0a Law for the following reason.(Sec.703 1.5,Business and Professions PERMIT ISSUANCE - 10.00- -
in Code:Any city or county which requires a permit to construct,alter, '
S Q p improve,demolish,or repair any structure,prior to its issuance,also 'ELEC.CONTR. - LIC.NO; ELEC.
O u requires the applicant for such'permit to file a signed statement that - f TOTAL tlV PERMIT TO
u whe is licensed pursuant to the provisions of the Contractor's License
H z¢ Law(Chapter 9(commenciogwitli Section 7000)of Dwision3ofthe
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
S f o the basis for the alleged exemption.Any violation of Section 7031.$ STORIES TYPE CONSTR.
e. by any applicant for a permit subjects the applicant to a Civil penalty • ALTER-DRAIN&,VENT-WATER (EA.) 5.00
of not more than five hundred dollars($50().):
' -❑ 1,as owner of the property,or my employees with wages as ' BACK FLOW PROTECT.DEVICE 4,00 DCO.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 "
Code:The Contractor's License Law does not apply Co an owner of - -
4x'1'_1$, property 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 improve- GAS-EA.SVSTEM-_1 6.00 *. '
mens are not intended or offered for sale.If,however,the building
yt7 or improvement is sold within one year of completion,the owner-. GAS-_EA.SYSTEM:OV ER 4(EA.) 2.00 BUILDING USE-
fw builder will have the burden of proving that he did not build or im- RES INDCON PS Other
` - prove for purpose of sale.).' INDUSTRIAL WAS TE INTER. 30.00 '
E) w
1,ro oner of the property,am exclusively contracting with, ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-,1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO..
I 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 project9 with u contmctoos)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 , TRACT NO. PARCEL NO.
❑ I-am exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 6.00 ' ,-
reason .
Owner - Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER'TREATING EQUIP. . 5.00
•I hereby affirm that 1 have a certificate of consent to sef-insure. _ • ZONING ENG.SITE NO. -
or a certificate of Workers'Compensation Insurance,or a certified -
copy thereof(Sec.3800,Lab.0).' 7—mE RAZ/
Policy No Company
O - _
.
❑ Certifiedleopy is hereby furWhed. I: FIRE SPRINK ENERGY T-24
Z Z )P Certifien--x y is .tiled w' the inspection division. ' MISC.-' •• ' ..REFER TO ORD. ❑ ❑ ❑
p App ant�gc V N V N
I— rn VVV PERMIT ISSUANCE - - 10.00 FLOOD ZONE . A.L.u.a
— CERTIFI ATE OF EXEMPTION FROM WORKERS' _
W > - COMPENSATION INSURANCE PLG.CONTR. - ., LIC.NO. PLG.
d O (This Section need not be completed if the permit is for one TOTAL V❑ NE] V ❑ N❑
Z) Z hundred dollar4($100)or 16.)
U O 1 certify that in the performance of the work for which this per- pTY. . -MECHANICAL PERMIT FEE FEE SUMMARY
I— mit is issued,I shall not employ any person in any manner so as to -
O W became subject to the Workers'Compensation Laws of California.
Date ' Applicant- ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APP LICANT',•If,after making this Certificate,of Ex-
Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE -
U such provisions or this permit shall be deemed revoked. - AIR HANDLING UNIT(TO 10)000C.F.M:) 4.00
•CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000C.F.M.) 6.00 '' SEISMICFEE
'I hereby affirm.that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(See. MICROFILM
3097,Civ.C.). HEATING'UNIT (TO 100,000,B.T.U.). 8.00
Lender's Name HEATING UNIT(OVER 100,000B.T.U39.50 ELECTRIC �Q
0-0
Lender's Address
}d•'S's"� 1 certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) ' 4.00 -
h' {° information is correct. 1 agreepo comply with all city and county PLUMBING
tw$ ordinances.and state laws relating to building construction, and _ .BOILER-POMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of-this city to enter upon the - BOILER-COMP IOVBrtO0,000BTUISEE FEESCH. MECHANICAL.-
above-mentioned property 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
may in an way accrue a I at said i y in copse uence of4he PERMIT ISSUANCE 10.00
,rami is permit MECH.CONT.- LIC.NO. - MECH.
6 C roTAL TOTAL
tAl
\� Ign ure of Applicant/ tractor ate _
OFFICE COPY