8282 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
J&LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
a1nLDINGAPPLICATION & PERMIT
ADDRESS CP
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 8282
OWI,IENAMER6CvP2T'6,.✓C. Tisa- PLAN CHECK VALIDATION
R'I i v0 J,�
DTV. ELECTRIC PERMIT FEE
1 QS PHONE
CONiRA TOPS
rvAl.� � UTLETS-SWITCHES-RECEP 10.00/1.00
D
ALIGHTING FIXTURES. 10.00/1.00
DESS PPLIANCES-RESIDENTIAL 4.00
R's ADDRESS
PHONE PANELS 10.00 r.ATIF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
on PANELS (OVER 200 AMP) 20.00
ENGINEER1 /��fJ /,
:fFc» 62^SScc.uc.Na/`7 D0� SIGNS TRANS. 3.00
ARCH.OR EN PERMIT VALIDATION
ADDRESS �IAR�$ 3- S""N'�-�9 Ss1Nltfur.LI? SPECIALCIRCUIT 5.00
SR D zl ,Sts-7o EMP.METER OR POLE INS. 20.00 PAIL)
APPLICANT'S /30l -g IaR-Y 1-t-- MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 JUL _ 1095
woo
• LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City 9k 9mwV
av u I hereby affirm that 1 am licensed under provisions of Chapter 9 S
N a (commencing with Section 7000)of Division 3 of the Business and BL ELECT. PLG. MECH.
H y i Professions Code,and my license is in full force and effect. El ❑ ❑
c i T o License Class Lie.Number
Date Contractor
`a,s 1 BUILDING PERMIT
M o i U' OWNER-BUILDER DECLARATION INFORMATION
X
;
A.H I hereley,affrm that I am exempt from the Contractor's License MISC.- REFER TO ORD
VALUATION $/FT.
Fuoj Law forthe following reason, 7031.5,Business and Professions PERMIT ISSUANCE 10.00
f �A0S Code:Anycityorcounty which requires apemnit to construct,alter,
¢ improve,demolish,Or repair an structure,prior to its issuance,also ELEC.CONTR. LIC.NO.
¢ s O P P Y P ELEC.
Ott requires the applicant for such permit to file a signed statement that TOTALRM T
w$y he is licensed pursuant to the provisions of the Contractor's License _
Hi> Law(Chapter 9(commencing with Section 7000)of Division 3 of the
¢ Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
M_0 the basis for the alleged exemption.Any violation of Section 7031.5 RIES %TYPECONSTR.
. 9§ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00 Z
of not more than five hundred dollars(5500).):
❑ I,as owner of the properly,or my employees with wages as BACKFLOW PROTECT. DEVICE 4.00 OCC.GROUP RES. NITS
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
"t 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 60. .FL//OO��1R AREA TOT ACREAGE
himself or through his own employees,provided that such improve. 1/
hients mself enol intended or employeeffered for sa e.provided
that such
building GAS-EA.SYSTEM-1INC.4OUTLETS 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- B ILDING USE
p v fur purpose of sale I RES IND CON PB Other
1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ O ❑
lice ed contractors 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 contractors)licensed pursuam to
the Contractor's License Law. SEWER-SAN ITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
O I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00 7
reason
Owner _ a WATER SYSTEM 5.00
ACC.ITAACC FILE NO.
WORKERS'COMPENSATION DECL A ION WATER TREATING EQUIP, 5.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec 3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z - EI Certified copy is filed' with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y❑ N❑ Yo No
~ vaPERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LUCOMP- CERTIFICATE E EXEMPTION FROM WORKERS'
W ENSATION INSURANCE PLG.CONTR. LIC.NO. PLO. Y N� Y NE]
o (This section need not be completed if the permit is for one TOTAL
0 Z hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which Ibis per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
I- m' issued,1 shall not employ any person in any manner so as to
L) 's c subject to(hor
e Wkeri ns
Compeation Laws of California. I
D ApplicantBUILDING
ALTER OR ADD TO MECH. 5.00
N OTICE TO APPLICANT: If,after making this Certificate of Ex-
F ? emption,you should become subject to the Workers'Compensalion APPLIANCE 5.00 PLAN CHECK 3
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this Permit shall be deemed revoked. AIR HANDLING UNIT ITO 10=CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance o the work 1'or which I permit is issued(Sec.
30nder's .C). . AtiK r Ma�y�r>;=` HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address.5' I HEATING UNIT(OVER 100,000 B.T.U.)9,50 ELECTRI
�����' //�
1 certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBIN
ordinances and state laws relating to building construction, and BOILER-COMP 13 H.P.Or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. 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, cos and expenses which - CONST.TAX f!/�
may iPERMIT ISSUANCE 10.00 n any way occ ga' sai it consequen a of the
If gof ' perno MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
ignal o ApP sen Contractor Date
OFFICE COPY