8261 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATIONPERMIT NUMBER
BUILDING (( �� APPLICATION & PERMIT
ADDRESS I Oar �4 1 )0,RQD1a CQ_. 8261
`4L {1/ BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
QTY. ELECTRIC PERMIT FEE
PMON Qc.Ct
CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00
E
1- uc.NO. LIGHTING FIXTURES 10.00/1.00
cONTRACTOR)�� n 1� APPLIANCES-RESIDENTIAL 4.00
AD SS Wel 1 1
Ck
PHOry PANELS 10,00 DATE OF APPLICATION
ARCRITECTLA
PANELS (OVER 200 AMP) 20,00 PN CHECK FEE P.C.NO.
GR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRRE°Ss Ervc' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 ,r
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS J
SERVICE CHANGE 20.00
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a v U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE OATE
w G n (commencing wilb Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
R y z Professions Cod , nil nLi is in full fo ❑ ❑ ❑
Z O m -
Professions
Cc
Lic.Numt�{.f�
o O Date J_S1 Z C.Rhoulol�$'!1
a y s BUILDING PERMIT
¢ ¢ w < OWNER-BUILDER DECLARATION
o a MISC.- REFER TO ORD INFORMATION
wLL N I hereby al'1'irm that 1 am exempt from the Contractor's License
u O ¢ Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
� - v, Code:Any city orcounty which requires a permit to construct,alter,
IF
to¢l- 2 Improve,demOl6lh,or repair any structure,prior to Its issuance,also ELEC.CONTR. LIC.NO. ELEC.
aa
O LL requires the applicant for such permit to file a signed statement that
TOTAL PER
T
u w m he is licensed pursuant to the provisions of the Contractor',License
Fe
s- Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe 97-
E O Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
u , 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 05000.):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work.and the structure is nut OCC.GROUP RES.UNITS
intended or offered for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 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.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner. GAS-EASYSTEM-OVER 4 IEA) 200 BUILDING USE
builder will have the burden of proving that he did not build or inn- . . .
- RES IND CON PB Omer
prove for purpose:of mle.). INDUSTRIAL WASTE INTER. 30.00
LI 1, El ❑ 1:1 ❑
1,as owner of the property,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
contracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under See ,B.&P.C.(or this WATER HEATER W/VENT 6.00
feamh
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSAT1ON DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconsent to selfinslrc, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insur lice,or a certified
copy thertyrh�Q G.)
Policy 1'(dCii
O ❑ ere ificd copy is hereby(....shed. FIRE SPRINK ENERGY T 24
Z Z 1'f Cert iL r��I�Y If ,,LuyWy�I�h (�{yhspection division. MISC.- REFER TO ORD.
0 Applicant YSll �-,+ �` '� V❑ N❑ V ❑ NF]
2 W CER'n FICATEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.0 C.
W > COMPENSATION INSURANCE PLG.CONER. LIC.NO. PLO. v❑ N❑ v ❑ N❑
d 0 (This Section need not be completed if the permit is for one TOTAL
Z hundred dollar,IS 100)or less.)
U O 1 certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
P rout it is issued.I Shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
n Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F- Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such Provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=0C.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. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.0.).
Lenders Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information u correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to comply
building construction, and BOILER-ODMP(3 H.P.or 100,000 B.T.U.) 6.00 �1r
hereby author, representazives of this city m enter upon the BOILER-0 M_P(Over 100,000 BTU)SEE FEE SCH. MECHANICAL .�
above-mentioned property for inspection purposes. C�
(We) agree to Save, indemnify and keep harmless the City of MISC.- R ER ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
PERMIT SSUANCE12 0.00
may in any way accrue against said City in conscyue c of[he e
m of this permit. , I '• I MECH.CONT. ��G MECH. TOTAL
S' ature of Applicant/Contractor ,f�s�B3�LL c ' ((XII
�/rl OFFICE COPY