C8285 �1 IT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
JIING POJ
REC IDENTIFICAT PERMITNUMBER
�QPPLICATION & PER
ADL yC7�1� -/tb7�2 it/ 7e D�/
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
NAME G 'TD '1�2. PLA C LIDATION
• "�Q-�' •� CITY. ELECTRIC PERMIT - FEE
� PHONE A sii �}
NAME Ac RS OUTLETS-SWITCHES-RECEP 10.00/1.00 ~� 4� 1Jry��
• uc.No. LIGHTING FIXTURES 10.00/1.00 'City of CV
cONTRACORs
ADDRESS APPLIANCES-RESIDENTIAL 4.00 GC IOo
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.No.
OR
ENGINEER kjFRy
I52SMN NO, xMp�' SIGNS TRANS. 3.00
ARCH,OR ENG. ^1 -� Suy11'tr.y SPECIAL CIRCUIT $,QQ PERMIT VALIDATION
ADDRESS /�
--4)GA 1 2I EMP.METER OR POLE INS. 20.00
APPLICANTS 1 ��Q'�Y MOTORS SEE FEE SCH.
ADDRESS
55 /
-S µn. vq (Q, ,3TJ �6 SERVICE CHANGE 20.00 �,r (Ii1
w 02 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 %� Ll
¢v u I hereby affirm that I um licensed under provisions of Chapter 9 ISSUANCE GATE
maw (commencing with Section 7000)of Division 3 of the Business and BL C. ELECT. PLG. MECH.
H m z Professions Code,and my license is in full force and effect. ❑ El ❑
FZ O m - License Class Lic.Number
mH w Date Contract., _
`a y f BUILDING PERMIT
¢ ¢ w a OWNER-BUILDER DECLARATION INFORMATION
w3:o N 1 hereby affirm that I am exempt from lire Contractor's License MISC.- REFER TO ORD ygLunnON $/FT.
FLLDa Law for the following reason lSec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code'.Any city or county which requires a permit to construct,alter,
I1y�J.lJ1 ��
ce Q Gimprove,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO.
al
-DLL requires the applicant for such permit to file a signed statement that TOTAL PERMI TO
K
$ he is licensed pursuant to the provisions of the Contractor's License
Lvw(Chapmr9 N.mmcncingwith Section 70001of Division 3 of the ,, I
- a Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
K F the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CON T
i ; by any applicant for a permit subjects the applicant toacivilpenalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
more than live hundred dollars($500H.):
Wcir1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RE Nlrg
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
Code:The Contractor's License Law does not apply to an owner of '
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SE FPF�d AREA TOTAL ACREAGE
himself re through his own employees provide(] eve such improve-meats such
building GAS-EA.SVSTEM-l1NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not huild or im- R IND CON PB Omer
privy for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
�i I,as owner of the property.am exclusively contracting with E] El El 1:1sedcontractors 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 docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
tine Cicteforsuch projects with acontractnr(s)licensed pursuant to SEWER-SAN ITARY-STORM EA.2001(/10.00 TRACTNO PARCELNO.
tire Conuuctor's License I.v
❑ tum • cm (under u c .B.&P.0 for this WATER HEATER W/VENT 6.00 ��
reason
Owner Date WATER SYSTEM 5.00
CC.DAT ACC.FILE NO.
WORKERS'COMPENSATION DECO ION WATER TREATING EQUIP, 5.00
1 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 thereaf(Sce.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection division.
O Applicant MISC.- ' REFER TO ORD. Y❑ N❑ Y ❑ N❑
Cr CERTIFICATE OP EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This section need not be completed if the peril is To one TOTAL Y❑ N❑ Y❑ NJO
Z hundred dollars(5100)or less.)
U 0 I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F 's issued,1 shall not employ any person in any manner so as to
U to subject to the Workers'Compensation Laws of California.O y Applicant ALTER OR ADD TO MECH. 5.00 BUILDING ICE 1O APPLICANT: If,alter making this Certificate of Ex-
emption,you should become subject to lire Workers'Compensation APPLIANCE 5.00 PLAN CHECKprovisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
lire performance r he work for which this per it is issued(Sea MICROFILM
3097.Civ.C.). �� U, �^ ��Z�- HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address�,�A/ "�'�:� y
1 certify that I have read oris applicationand slate that the above VENTILATION FAN (SINGLE) 4.00
Is0 information toco correct. I agree to complylywith all city and county PLUMBING
ordinances and stormconstruction.e laws rclg to building construction. and BOILER-CONP(3 H.P.or 100,0008.T.U) 6.00
hereby authorize representatives of this city to 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 Ore City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments,costs and expenses which CONST.TAX
cony in any way ace c against said 'yin sequence of the PERMIT ISSUANCE 10.00
T lis-!en MECH.CONT. LIC.NO. MECH. 21.
(/ TOTAL TOTAL
Igna are of I cans/ corse Dam 149 02-
OFFICE COPY