10264 APPLICANT TO FILL IN INFOR ATION WITHIN RED LINES - USE BALL POINT PEN ONLY
??? BUI DING'PROJ 51ThPERMITNUMBER
' aD,Lr, APPLICATION & PERMIT 10 2 6 4
No
r BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S
NAME PLAN CHECK VALIDATION
OTY, ELECTRIC PERMIT FEE
PHONE
NA CTORs UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO. LIGHTING FIXTURES 10.00/1.00
.o croR' PPLIANCES-RESIDENTIAL 4.00
A
PRO N PANELS 10.00 DATE OF APPLICATION
ARRCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
O
ENGINEER
LIC.140. ISIGNS TRANS. 3,00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 IpfTI.T VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ucANrs MOTORS SEE FEE SCH, MAR
SERVICECHANGE 20.00 yI' 2s 7986
D R TEMP.POLE 30.00 p! Of CUAglflno
' 02 LICENSED CONTRACTORS DECLARATION CI
a i w 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE GATE
rA a n (commencing with Section 7000)of Division 3 of the Business an BLDG. ELECT. PLG.
i Professions Cody,/IsW 'cense is in full force
G i H W License Class_L� Lia Number El El
Date Contractor
a se BUILDING PERMIT
g c te u OWNER-BUILDER UECLA AT INFORMATION
w ;LL N 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
L,
O a Law for the following reason.(Sec.7031.5,Business and Professions VALUATION $/F .
� - Code Any cllyorcounly which requires a permit to construct,alter,
PERMIT ISSUANCE 10.00
IS la ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC,
a iL D ¢ requires the applicant for such permit to file a signed statement that TOTAL
X $m he is licensed pursuant to the provisions of the Contractor's License PE MIT T
r z r Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
s- the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
nim by any applicant for a permit subjects the applicant toe civil penally ALTER-DRAIN& VENT-WATER IEA.) 5.00
of not more than five hundred dollars($500)):
❑ 1,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 5G.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
mems are not intended or offered for sale.If,however.the building GAS-EA.SYSTEM-I1NC.4OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 IND CON Pe Othe,
❑ 1,as owner of the property,am exclusively contracting with
licensed contractors to Construct the project(Sec.7044,BusinessLAWN 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 forsuch projects with a conlractods)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00PACT NO. PARCEL NO.
O I am exempt under Sec.-,BAVC.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE N0.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent In self-insure. ZONING
or a car,fic o rkers' ompensation Insur e,or a c tied ENG.SITE NO.
copy'her ( .),
Policy N
O rtir, deo hereb nish¢d. FIRE SPRINK ENERGY T.24
Z Z ❑ ertifie op is fi with t inspection division. MISC.- REFER TO ORD. � ❑ ❑
O Ap icunl Y N V N
w CER ATI: EXI5MP N ROM W PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.c.
Lila 0 COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
= Z I I Ibis section need not be completed it the permit is for one TOTAL Y❑ N[] Y❑ N
hundred dollars 1$100)or less.)
U O 1 certify that In the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
U. V mit is issued, I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
i Dalc Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
H Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of lite Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10.000CF.NL) 4.00
CONS'T'RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00C.F.M.) 6.00 S ISMIC FEE
1 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. CROFILM
3097,Civ.C). HEATING UNIT(TO 100,000 B.T.U.) 6.00
Lender's Name HEATING UNIT 100,000 B.T.U.19.50
Lender's Address ECTR IC
1 certify that 1 have real this application and shite that the above VENTILATION FAN (SINGLE) 4.00
• information n correct.I agree to comply with all city and count BOILER-COMP 13 H.P.or 100,000 B.T.U.) 6.0 - PLUMBING
hereby m and share laws relating t building construction, and
hereby authorise representatives of this city to enter upon dm
above-mentioned property for inspection purposes. BOI LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City I MISC.- REFER TO ORD.
Cupertino against . bilili , Idgments, costs and expenses which ONST.TAX
may i y w ace a st said City in consequence of tlm PERMIT ISSUANCE 10.00
gr -go tl' I .I ME CONT. LIC.NO. ECH.
OTAL TOTAL
u ,o App7canl Contractor Ua[s
OFFICE COPY