10283 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY =' s
BUILDING PROJECT I DENTI FICAT PERMIT NUMBER
BUILDING APPLICATION & DEF*
ADONE55
_ efi .N / BUILDING - ELECTRICAL-PLUMBING -MECHANICAL n n
3
Le
OwNER'5 ' PLAN CHECK VALIDATION
NAME TY. ELECTRIC PERMIT FEE
IyA.✓(sJLy/✓. �o PHONE
1W CONTRACTORS OUTLETS-SWITCHES
NAME -RECEP 10.00/1.00
Luc,No ILIGHTING FIXTURES 10.00/1.00
CDNTRACrDgs APPLIANCES-RESIDENTIAL 4.00
=PHONE ^ r PANELS IO.CO DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
Elc.No. SIGNS TRANS. 3.00 Iti 113
ADDDR'ESS ENa. SPECIALCIRCUIT 5.00 IDATION
ZIP EMP.METER OR POLE INS. 20.00 DEC 311W
ADDRESS
DDR
AMOTORS SEE FEE SCH.
DRESE55S /
1p_{�� �'I/,✓,n�FS S� c ��%/�0 SERVICE CHANGE 20.00 City of CUoeltino
0 o O LICENSIiD CONTRACTORS DECL ATION TEMP. POLE 30.00
u o I lo,mb affirm that I am licensed under - I ^\
< Zw y pmvivoni of Chapter` ,ISSUANCE ATE
(commencing with Section 7000)of Division 3 of the Business and BLD ELECT. PLG. CH.
rm i Professions Code,and my license is in lull force and effeci J ❑ ❑
z o m License Class-L'�6_Lic.Number
9 m - Date o 7 . Contractor
F F ^
s +BUILDING IT-�,. ;
w a OWNER-BUILDER DECLARATION
o o' ". MISC.- REFER TO ORD 1 'IN F.ORMATION...
4x ; LL H I hereby affirm that I am exempt from the Contractor's License VALUATION 5/FT.
au er Law for the following reason.tSec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a Permit to construct,alter,
Qau¢ a improve, emolish.or repair any structure.prior to its issuance,also ELEC.CONTR. -- UC.rv0. ELEC.
C S, requires tht applicant for such permit to file a signed statement that ,TOTAL PERMIT TO
a w m he is license ursuant to the provisions of the Contractor's License
Fzr Law(Chapter. Icommencing with Section 7000)of Division 3ofthe _
< Business and Pr ssiuns Coder or that he is exempt therefrom and QTY. PLUMBING PERMIT - 1 FEE- /t ,
f m the basis for the at ed exemption.Any violation of Section 703 L5 ` STORI S TYP CONSTR.
P- _ by any applicant 1'or emit subjects the apphaanr toaclvil penally
ofnotmom than liven died dollars($5001
ALTER-DRAIN&VENT-WATER IEA.) 5.00
❑ I,as owner Of the perry,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation.w o the work, and the structure is t 1 OCC.GROUP RES.UNITS
intended or offend 1'or sale I 'C. 7044. Business and Pr cions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License w does not apply to net of p
property who builds or improves t con,and wh es such work /� FIXTURES-PER TRAP 5.00
50.FT.FLOOD AREA TOTAL ACPEAGE
• himself or through his own employees, erovid• I such improve.
mems are not intended or of feted l'or sx owcveo tlmu` id Jing GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one ytn ompletion' the owner GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 OIL IN uSE
builder will have the burden of pr g that did not build or im- RES D CON PB Omer
prove for pt,rpoe-of sale.). INDUSTRIALWASTE INTER. 30.00 ❑ ❑ ❑ ❑
❑ h as owner of the pr r[y,am exclusively attracting with
licensed contractors to strict the project(Sec. , 4, Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Cod a Contmetor's License Law due or apply
to an owner of perry who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts fo ch projects with a contractonsl licensed pursuant to
the Contoris License Law. / SEWE ANITARY- TORM EA.200ft/10.00 `op, TRACT NO. PARCEL NO.
❑ an exempt under Sec---B41AC.for this / WATER HEATER"W/VENT 6.00 lr
reason
Owner Date / WATER SYSTEM 5.00
S ACC.DATE ACC.FILE NO.
WORK ERS'COAIPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to sel Ginsure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
Copy thercof e�gJB Lab CA
"', ���d
Policy No SS ompooy /f
O ❑ Certified copy is bereby[umished FIRE SPRINK ENERGY T 24
Z Z � Certified copy flu ith the•c icy inspection division.
O Applicant " _�/.2•cw MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
M w CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 /O-At FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG CONTR I LIC.NO. PLG.
d O (This section need nut be completed if the Permit is for one �y//»%N/ ✓�- /�;/i3 OTAL //,. Y❑ N❑ Y ❑ N❑
Z hundred dollars(SI00)or less.)
U O I certify 't in the pertisrmanee of the work for which this per- QTY. MECHANICAL PERMIT FEE ' •FEE SUMMARY
LL I- mit is iMued,I s not employ an)' person in uW.manner so as to I -
Ow become subject to chi keri Comm n Laws of California. BUILDING
OL Date Apphc' ALTER OR ADD TO MECH- 5.00
} to NOTICE TO APPLICAN ,a aking this Certificate of Ex-
? emption,you shot, Come subject toTheAVorkers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of Labor Code. you must tar Ith comply with FEE
U
so ch provi ns or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER ID000C.F.M.) 6.00 SEISMIC FEE
1 her
mm [hat then is a construction IendinRlssuen EXHAUST HOOD(WITH DUCT) 5.00
the peffermao[ the work for which [hi d ISee. MICROFILM
3097.Civ.C.). HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lenders Add ELECTRIC
1 certify that I have read this application and Strait,that the above VENTILATION FAN (SINGLE) 4.00
• information is cormc[. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby awlmrim represeriatives of this city m enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(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 any way acetum against said City in consequence of the PERMIT ISSUANCE 10.00
granting of this p•resit. r MECH.CONT. LIC.N0. MECH.
? TOTAL TOTAL ..-
Signature of Applicant/Contractor Date -
INSPECTOR COPY J� /