8281 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
I!BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
ADD ESSAPPLICATION & PERMIT /� 1
10990 m/R /tIG'Y e�, BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
/ OWNER'S x:*I.',, ,;qt V _ self . PLAN CHEC/f;VALIDATION
"AME QTY: ELECTRIC PERMIT ;FEE
WV F.J LULU PHONE
C NTRACTOR3
NAMEe/Q UTLETS-SWITCHES-RECEP 10.00/1.00
A)aq C14490v3 LIC.NO.Q�r` t)3a LIGHTING FIXTURES 10.00/1.00 3116K
f.ONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00 7jb
sb A l4 r• PHONE 2? --13 PANELS 10.00 Q DATE OF APPLICATION
OR
RCHITECT - PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO.. SIGNS TRANS." ' 3.00
AGGRESS ENo. SPECIAL CIRCUIT 5.06 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 (-
APPLICANT'S MOTORS
ADDRESS SEE FEE SCH. J
< SERVICE CHANGE n 20.00 q /�s
,,o o LICENSED CONTRACTORS DECLARATION" TEMP,POLE 30.00 d
<u u I hereby affirm that I am licensed under provisions of Chapter 9 % ';') ISSUANCE DATE
w <A (commencing with Section 7000)of Division 3 of the Business and , SLOG. ELECT. PLG. MECH.
I 7 i rofessions Code anQQjgy license is in full forcyni:ffA1O
p Z o icense Class_L/ :Lic.Number YL"7 7J
a, ; Ste3 U_(35 Contractor_ll-�Ewgcfa}i3 City of Cuper ino ❑ ❑ ❑
a y.s d �Y�W BUILDING PERMIT. X j
¢ ¢ a OWNER-BUILDER DECLARATION
o d v INFORMATION ,, .
E
; I hereby affirm.that I am exempt from the Contractor's License MISC.- REFER TO ORD
VALUATION E/FT.
o¢ Law for the following reason. 7031.5,Businessand Professions PERMIT ISSUANCE }ggg
5 u so-a Code:Any city or county which requiresa permit to construct,alter,
¢ a¢0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. J�
O LL requires the applicant for Such permit t0 file a signed statement that TOTAL oL PERMIT TO
w $m 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 E G
sr o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
2 I- the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR,
aF_ _ by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(5500).1:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.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
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work F IXTUR ES-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
ments are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner. GAS-EASYSTEM-OVER 4(EA.) 200
builder will have the burden of proving that he did not build or im- . . .
BUILDING USE
prove for purpose of sale.). I INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Othar
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ Cl
licensed contractors 10 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 contiactor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
Ilia Contractor's License Law. TRACT NO. PARCEL NO.
❑ Ion exempt under Sec..,BAP.C.for Otis WATER HEATER W/VENT 6.00
eaten
Owner _ Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPF-NSATION DECLARATION WATER TREATING EQUIP. 6.00
I hereby affirm that I hav�j cy/{I fi leaf consent to self-insure, ZONING ENG.SITE N0.
err cert Hila to WpEhyS pol��dn Insurance,or a certified
co .y No x cA A 2JC4,L.COJnp
Policy No. Company
0 ❑. Certified copy is hereby furnished. FIRE SHRINK ENERGY T 24
Z Z O Cerifm p s I d wish the city(inspect' n dys _ ivisior�y MISC.- REFER TO ORD. ❑ N Y ❑ No
A f Car' /b'b�a-bNRfdP'(9 Y
~ PERMIT ISSUANCE 10.00
Cr CF:RTIFI0ATE OF 00MPFNSATON INNSURAMPTION ONCE WORKERS' PLG.CONTR. LIC.NO. PLG FLOOD ZONE A.LU.C.
CL Z( This section need not be completed if the permit is for one TOTAL Y E] C3 N
N❑ Y ❑
hundred dollars($100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT "' FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
y Date Applicant BUILDING
} He NOTICE TO APPLICANT: If,after making this Certificate of nix- ALTER OR ADD TO MECH. 5.00
F Z emption,you should become subject to the Worker'Compensation APPLIANCE 5.00 PLAN CHECK
U
provisions
of (he Labor Code, you must forthwith comply with FEE
such
p permit shall be deemed revoked. AIR HANDLING UNIT(TO 10AUDC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.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 permit is issued(Sec. 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
Lender's Address ELECTRIC
I certify that l 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 PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000B.T.U.) 6.00
hereby authorize representatives this city eater upon the BOILER-COMP(Over 100,000STU)SEE FEESCH. MECHANICAL
above-mentioned properly for inspection purposeses.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
. Cupertino against liabilities,judgments, costs and expanses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any wa ccrue against said City in consequence of the
granting of lhi a lit. t, - iI MECH.CONT. LIC.NO. MOTAL
TOTAL
Signa I' licanf/Contractor Data
OFFICE COPY