9284 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES = USE BALL POINT PEN ONLY
BU LD1 NG PROJECT I DENTI FICATI ON , PERMIT NUMBER
BUILDING CV qfi APPLICATION & PERMIT
7 AOD
- 2y� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 9 8
RE s
CasINER'S PLAN CHECK VALIDATION
Niy�I R NE`1 OTY. ELECTRIC PERMIT FEE
IMF /
CONTRACTOR'S O
NAME _ �• /� .� / 5 UTLETS-SWITCHES-RECEP 1LT.00/1.00
d C-I w'uc.No LIGHTING FIXTURES 180/1.00
CONTRACTOR'S
ADOq ape //_ PPLIANCES-RESIDENTIAL 4.00
Cr$,j ONyb,b (YUJ PANELS 10.00 DATE OF APPLICATION
ADRRCH ECT PANELS (OVER 200 AMP) 20.08 PLAN CHECK FEE NO.
ENGINEER
LOC.NO. SIGNS TRANS. - 3.00
ADDREis�ENo SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 I ry/✓l
APPLICANTS s MOTORS SEE FEE SCH. �1 I� f1
ADDRESS l
tSERVICE CHANGE' 20.00
f 1 w0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE - 30.00
Q U U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
N rt (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH,
r o z Professions CoJ nd 'cense min full fur' a e
License CIsss Lic.Number El El
-
'� r � Contractor
m I BUILDING PERMIT
I[ Q n U O N,R- ILUER UF,CLA A"TION
E
I- 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD INFORMATION
L N o Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE VALUATION S/FT.
Code Any city or county which"requires a permit to construct,alter, -
Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
allo u ..yours the applicant for such permit to file a signed stm'mem that TOTAL {0 PERMIT TO
''w he is Iiceru,d pursuem to the provisions of the Contractor's License
H z
¢ Law(Chapter 9(commencing with Section 7000)of-Division 3 ofthe
4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
w L-$ the basis for the alleged exemption.Any violation ofSeuion 7031.5 STORIES TYPE CONSTR.
u ; by any applicant for a permit subjects the applicant to civil penally
of not more than five hundred dollars(5500).): ALTER-DRAIN -WATER (EA.) 5.00
❑ I,as owner of the property,or my employees with wags as BACK F LOW PROTECT. DEVICE 4.00 OCG GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offend for sale(Sec. 7044; Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Cod,:The Commeter's License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such improve-
merits amnot intended oroffered for sale.If,however,the building, GAS-EA.SYSTEM-.11NC.40UTLETS 6.00
or bnprovll have
is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
beiurip will have the harden of proving Oct he did not build or un-err- BUILDING USE
prove for purpose of sale.). I RES IND CON PB Other
❑ I,as owner of the INDUSTRIAL WASTE INTER. 30.00 ID 11
11 El Elproperty,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.
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
t for such projects with a erontraemr(i)licensed pursuant
he Co SEW ER-SANITARY-STORM EA.200ft 10.00
h,Contractor's License taw. / TRACT NO. -PARCEL NO.
❑ 1 am excmpt under Sec. ,B.&P.C.for this WATER HEATER W/VENT. 6.00
reason'
Owner [)at, WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent to self-inane*
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO,
copy ther ,(Se- 30�'{.h.
PohcY No.sSQ-,i'tC
❑ Ccrthird copy is hereby hom,hed. FIRE SPR INK ENERGY T 24
Z. J?l;Cetlified copy is fled with the city inspection Division. MISC.- REFER TO ORD. ❑ ❑ ❑
F APPlicant ❑ ry v v N
}e y
CER'I']FICA'rE.OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.0
LU > COMPENSATION INSURANCE PLG.CONTR, LIC.NO. PLG.
a. 0 (This section need not he completed if the Permit is for one TOTAL Y El Ely 11N❑
hundred doll...IS 100)or less.)
U O 1 certify that in the performance of tise work for which this per- DTV MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ'any person in any manner so as to
O W become subject to the Workers'Com Pens'ution Laws of Calil'orl -
CL Date-Applicant BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of fix- ALTER OR ADD TO MECH. 5.00
F Z emptier,you should became subject to tire Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
C..) such provisions or this permit shall be deemed evoked. AIR HANDLING UNIT(TO 10=11F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0MC.F.M.) 6.00 SEISMIC FEE
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 permil is issued tSec. MICROFILM
3097,Civ.C.l. HEATING UNIT(TO 100.000 B.T.U.) 8.00
Lender's Name H EATI NO UNIT(OVER 100,000 B.T.U.)9.50 �O
Lender's Address ELECTRIC
1 certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• ordinances is wren. I .gree to comply with all city and cotmtd BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws elating to building l city and
c. my
hereby authorize representatives of this city to enter upon the BOILER-COMP IOVe!100,000 BTU)SEE FEE SCH.
above memloned property for inspection purposes, MECHANICAL
(We) agree to save, indemnify and keep harmless the City of - MISC.- REFER TO ORD.
Cupertino again(liabilities,judgments, costs and expenses whish CONST.TAX
may in any ,y accrue against s1tl Cit N conseyuc a of the PERMIT ISSUANCE - 10.00
grantingof s cmtif a1 / MECH.CONT. LIC.NO. MECH.
/( ` TOTAL TOTAL
Sig ure of AppBcan C tractor Dat'
- OFFICE COPY