10076 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
aooAEss 057,E rF1RR1 I onE - BUILDING -ELECTRICAL-PLUMBING-MECHANICAL- 10076
OWNER PLAN CHECK VALIDATION
//1111^^^��� _(y`''�.Jo� OTY. ELECTRIC PERMIT FEE
�L)1Fs ) PHONE / WI .
• N°e"E""trolls UTLETS-SWITCHES-RECEP 10.00/1.00
eNA C LIC.No.aPRL:J%nLIGHTING FIXTURES 10.00/1.00
on[sv rolls p - 1 PPLIANCES11
-RESIDENTIAL 4,00
O
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEEP.C.NO.
on
PANELS (OVER 200 AMP) 20.00
ENGINEER
L.C.No. SIGNS TRANS. 3.00
AR, ENG. PERMIT VALIDATION
ADDRESS
ss SPECIAL CIRCUIT 5.00
zev ITEMP.METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCH.
AS
SERVICE CHANGE 20.00
. 02 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
au I hereby affirm that I am licensed under provisions of Chapter 9
vi 2 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
B. BLDG. ELECT: PLG. MECH.
I- z Professions Code d I i is In,,,,
n full f
0 i`�o Use,
iela Lia um
_ Date Contm �l
Q y le J
¢ ¢ w OWNER-BUILDER UECLARATIO BUILDING PERMIT
wu 1;; 1 hereby union that I am exempt from the Contractor's License MISC.- REFER TO ORD INFORMATION
u O Law for the following reason(Sec.7031.5,Burmesand Professions VALUATION $/FT.
- g Code:An cit PERMIT ISSUANCE 10.00
Any yon coo my which structure,
requires Permit to construct, also
s o o improve,demolish,or repair any strut tore,prior n its issuance,also ELEC.CONTE. LIC.NO. ELEC. I
- LL require the applicant for such permit to file a signed statement that TOTAL
w he is liceed pursuant to the provisions of the Conmiclors License PERMIT TO
ns
F z a
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢ � $ the hasis forthealleged exemption,Any violation ofSeclion7031.5STORIES TYPE CONSTR,
by any applicant for a permit suhjectsthe applicant Ina civil penalty ALTER-DRAIN (EA.)olnot mort than five hundred dollars(S500).):
❑ 1.u a owner ut the properly,or my employes with'watn as BACK F LOW PROTECT.DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will property,
the work,and the slwith, 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 guilds or improves Ihroon,and who does such work FIXTURES-PER TRAP 5.00 sa FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employers,provided that such improve.
ments are not intended or offered for sale.IL however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvemem 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 1.aso nee of sale.). RES IND INDUSTRIAL WASTE INTER. 30.00 ❑N
Pe Does,
❑ L as owner of the property,he reject(SeI. 7044,ing with
licensed contractors: construe the project(Sec. 7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSE RS PARC EL NO.
and Professions Code:The Contractor's License Law docs not apply
to antr owner of property who builds t r improvesthereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contranors s)licensed punmm to
she Contractor's License Law.- SEWER-SANITARY-STORM EA.2008/10.00 TRACT Na. PARCEL NO.
❑ lam exempt under See.-,BAP.C.Ibr this
rCaslln WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK 17 RS'COMPENSATION DECLARA'IION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Comp nsxtion Insumnee,or a erli Gad ZONING ENG.SITE NO.
copy the .J
Policy N
0 ❑ Cerci d rely is hereby furnished.
` � FI ESPRINK ENERGY T-24
Z Z R Ce c`ppy is�esLsvit7i,Ihll Li Ally inspection division. Y 0 NE) Y E] SNE
FO pP¢an _ sG��A�"tGFKIf LI-r MISC.- REFER TO ORD:
fLN CERTIFICATE$1'PxIiMPTION I'ROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.uc.
LU > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG
CL O (This Section need not be emoideted if the permit is far one TOTAL
� Z hundred dollars(5100)or less.)
U O 1 certify that to the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
(J_ I- mit is issued,1 shall not employ any person in any manner NO as to
U became subject to the Workers'Compewetion Laws of California.
i Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ w NOTICE TO APPLICANT: If,xfler making this Certificate of Ex- -
� ? creptlon,you Should become subject to the Workers''Compensution APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Coda you must forthwith comply with U FEE such provisions or this permit shall be domed revoked. AIR HANDLING UNIT(TO 10=11F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNI p00C.EM) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD( H'DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097.Civ.C.). HEATING UNIT 1 0, T-ft.) 8.00
Lender's Name
Lcndcr's Address HEATI NGUNI ( 100,000 B.T.U.)9.50 ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (S 1 4.00
\�\
information n correct. I agree tog to b with all city and county BOILER-Cow(3 r 00,000B.T.U.) 6.00 PLUMBING
inform do and state Iowa relating to building Ll cit radion, and
hereby authorize representatives of this city to anon upon the LER-COMP (Over 100,000 BTU)SEE FEE SCH.
above-mcnlioned prepeHyfor inspection puity to. BOI MECHANICAL
(we) agree to save, indemnify and keep harmless the City of MISC.- r FERTO ORD.
Cupertino against wac.rjudgments, costs and expenses which PERM ISSUANCE 2 10.00 CONST.TAX
Cu in an way accrue liabilities,awl said CII in consequence of the
grant this PCnmL MECH.CONT. LIC.NO. MECH.
(o UIQ TOTAL TOTAL
S f real Applicant/Contractor ate �n
OFFICE COPY