8780 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDINGAPPLICATION & PERMIT
AO /
oD.rS.
oREss
UAl t-dNa"b" A9_1ILDING-ELECTRICAL-PLUMBING-MECHANICAL
878
OWNER'$ I PLAN CHECK VALIDATION
NAME T ELECTRIC PERMIT FEE -
• vHONE Cz1✓
rCiaeTBn °o (( t UTLETS-SWITCHES-RECEP 10.00/1.00
blLl LIGHTING FIXTURES 10.00/1.00
FooRE ° S F__1 / PLIANCES-RESIDENTIAL 4.00
NELS 10.00 DATE OF APPLICATION
aRCHIT CT
OR
PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3,00
ADDRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
zlv TEMP.METER OR POLE INS. 20.00 n
ARMOTORS SEE FEE SCH.
ADDRESS
E55
SERVICE CHANGE 20.00
,00 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 ! U
< o w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
H G w (commencing with Section 7000)of Division 3 of the Business BLDG. ELECT. I PLG. MECH.
F m z Professions Coda,and my license is in full force a
zO o - License Class Lie Number ❑ ❑ ®, ❑
o z r o Date Contractor '
¢ y s f �(f'---� BUILDING PERMIT
¢ R w ¢ J N- UER DLCLA RA'iION INFORMATION
K o de' MISC.- REFER TO ORD
w ;n H I hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
.. O a Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
y0 Code:Any city or county which requires a permit to commuct cher,
� Q Q p Improve,demolish,or repair any Structure,prior In It$issuance,also ELEG CONTH. LIG NO. ELEC.
- O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
E
m he is licensed pursuant to the provisions of the Contractor's License �1
R z
Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe
¢ L
Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
(c = $ the basis for the alleged exemption.Any violation of$ectmu 7031.5 STORIES TYPE CONSTR.
n ; by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S5000:
❑ 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 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 builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.PLOD"AREA TOTAL ACREAGE
' himself re through his own employees,pm 11,ho that such imprdve-
mentsarenolintendedorofferedforsale.ILed that. themprong GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA) 200 BUILDING USE
builder will have the burden of proving Oma h . . .
e did not build or im- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the properly,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 properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for suchprojects with a comractorf s)licensed pursuant to
License
L
the Contractor's License Law. SEWER-SANITARY-STORM EA.2001t/10.00 TRACT NO. PARCEL NO.
❑ Iumexemptunder Sec. ,B.&P.C.forthis WATER HEATER W/VENTpAJI0 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE N0.
WORK ERS'COMPENSATION DECLARATION WATER TREATING E IP^ �(j0
I hereby affirm 111.1 1 have a certificate.1-consent to self-i...m. ZONING ENG.SITE NO.
coeer yy'�{�o W p nsmm Irks Ince r i er.1 is
p t y(glf�c a C. , $
O Pol cnilific� l/'op stem y ished FIRE SPRINK ENERGY T 24
Z Z ❑ Cerlific p d with 0 i y iI ..tion di 'si I. MISC.- REFER TO ORD.
O Applicant - v❑ N❑ V ❑ N[]
~ U, PERMIT ISSUANCE 10.00
cc CIIRTIF 'AT'Ii OF EXIiMPI ION PROM WORKERS' FLOOD ZONE a.L.uF.
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This Section eed not be completed if the permit is for one TOTAL Y❑ IN Y ❑ IN
' Z hundred dollars(S 100)or less.)
U O 1 certify that in me performance of the work for which this per DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL j- mil is issued, I shall not employ any person in any manner so as to
U become subject to the Workerx'Compensation Laws of California.
W Date Appllcim ALTER OR ADD TO MECH. 5,00 BUILDING
} m NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F, Z .option,you should become subject to the Workers'Compensation APPLIANCE 5,00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply wid FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00
CONSTRUCTION L17NDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.16.00 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
(-coda's Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that 1 have read this application and slate 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 Io building Construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgntenls, cost d expenses which CONST.TAX
may in any way Sec See against said City sequence of the PERMIT ISSUANCE 10.00
gr' Ijng of this Pimi _ / / ,CONT. LIC.NO. MECH.
l TOTAL
Si lure of Applic t/ omractor 0.)e
OFFICE COPY