8897 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES.- USE BALL POINT PEN ONLY t�7.Y
BU LDI NG PROJECT I DENT]FICA PERMIT NUMBER
OUILOINc APPLICATION & PER
• AOORFss p ,S/
9//Yp jJ/�/�Qcp�•j BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 8897
OWNERS - - PLAN CHECK VALIDATION
NAME
• 9�� /I_ i�- QTY. ELECTRIC PERMIT FEE
(// C./TPNONE
CONTRACTORS
NAM �^ UTLETS-SWITCHES-RECEP 10.00/1.00
E�.tJ1iQAl �i/Pi �ic. /7/•S-�� LIGHTING FIXTURES 10.00/1.00
CONT Ess rolls �. APPLIANCES-RESIDENTIAL 4.00
&e2��fl�'/fS ?NEay�_ ,�' PANELS 10.00
DATE OF APPLICATION
AN CIT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.No. SIGNS TRANS. 3.00
aoo est ENG. SPECIAL CIRCUIT 5.00 P _ MtOATION
ZIP EMP.METER OR POLE INS. 20.00 APR L/'
moo Ess s MOTORS SEE FEE SCH. lir
��if/.P�ES oma. os f$�//�•� SERVICE CHANGE 20.00 1986
w o o LICENSED CONTRACTOR ECLARATION TEMP.POLE 30.00 City Of Ct(P- o
a u 1 hereby ullinn that I am IicenscA under provisions of Chapter9
2 i ISSUANCE GATE
H < w (commencing with Section 7000)of Division 3 of Business and - BLDG. ELECT. P MECH.
H N z Pmfessi0re Code antl m license is in full forceyl d eft•c.
Z O m - License Clu s�- Lic.Number
ww Date ConlroctoT�
Q w ¢ OWNER-BUILDER DECLARATION BUILDINGPERMIT
- o n " INFOR ATION
X g LL y 1 hereby ufl'um that I am exempt from the Contractors recite MISC.- REFER TO ORD
u
04 Law for the following reason.(Sec.7031.5,Businessand P fessions PERMIT ISSUANCE VALUATION $/FT.
r - 10
� w � Code'. ny city or county which tiles«supermit LLl col nlcl,alter, .00
to T, ¢FO improve, coolish,or repair uny structure,prior to i Issuance,also ELEC.CONTR. LIC.NO. ELEC.
TicO n requires(],I plicant for such permit to file a sig statement ilia( TOTAL
e w$m he is licensed onant to the provisions of the mractor's License TO
HZQ Law(Chapter9 Tormenting with Section? )of Division 3ofthe
E z D Business and Pro 'ons Code)or that he exempt therefrom and OTV. PLUMBING PERMIT FEE 01 W
M H S the basis for the alleg exemption.Any olation of Section 7031.5 STORIE TYPE ONSTR.
A. by any applicant for a itsubjects a applicant to a civil penalty ALTER-DRAIN (EA.) 5.00
of not mom than five bun ed dolls ($500).):
❑ I,as owner of the or crty or my employees with wages as BACK FLOW PROTECT.DEVICE 4,00. Dec.GROUP RE UNITS
their sole compensation,will he work,and the structure is not
intended or offered for sale . 7044, Business and Professions DRAINS-FLOOR,HOOF,AREA,COND. 5.00
Code:The Contractor's Lic se L does not apply to an owner of
property who builds or i roves Or on,and who docs such work FIXTURES-PER TRAP 5.00• SO.FT.FLOOR AREA TOTAL ACREAGE himself or through his n employees, rovided 0m[such im
mpro
orofferellorsal . f,however,the building / GAS-EA.SYSTEM-11 PIC.4 OUTLETS 6.00
or improvement is it within one year of mpletion,the owner. GAS EASYSTEM OVER 4 (EA) 2.00
builder will have a burden of proving that h id - . - .
Tint build or int- BUILDING USE
prove for purp of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ I,as o er Of tho,mperty,am exclusively c meting with
licensed c ractors to construct the project(Sec. 7044,BusinessLAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Prof cions Code:The Contractor's License Law does not apply
to an net of property who builds or improves(hereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 '
contr ts,�igjsuch projects with a contractor(s)licensed pursuant to
the mmetor's License Law. SEWER-SANITARY-STORM EA.200ft/10=. au TRACT NO. PARCEL NO.
❑ I and exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 6.00 (p-
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION UECLARAT ION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a Certificate ofconsent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab CA -�-•
Policy No_<f/ra23Company A/J/f�/!/h� INCL/t e
❑ Cetlifiedis hereby furnished FIRESPRINK ENERGY T-Z4
Z Z �Certified t y is�d with [h city irRpection division.
F O �plicant _--.��-a_�i�Ql= MISC.- REFER TO ORD. Y [3 NL] Y [3 rv[]
X N CF.R'fIFICATEOF EXEMMION FROM WORKERS' PERMIT ISSUANCE 10.00 O- FLOODZONE A.L.U.C.
L COMPENSATION INSURANCE PLG.CONT,R,.-/ (' LIC.NO.�j PLG. 7'
'
CIE. Z (This section nett not be completed if the permit is for one C- r/�/.� �l f/�/ /���j TOTAL/�/• Y[] N� Y � N�
bund« iyollars $100)orlfess
U O Icerf ' he perormJ
wme o1the wor r which this per, QTY. MECHANICAL PERMIT ' FEE FEE SUMMARY
EL F- mit is issued,>flnotploy any pets any manner so as to Sol become subjeers'Con at ion Laws of California.
Otn NOTICE. TODate t, for making this Certificate of Ex- ALTER OR ADD TO MECH. 5,00 BUILDING
emption,youo suhl 0 the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions oode, you m forthwith comply with FEE
suh provisioit shall be deeme ked. AIR HANDLING UNIT(TO 10=C.F.NL) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMICFEE
I her that there is a construa[on[end' ncy for EXHAUST HOOD (WITH DUCT) 5.00
the performance o t which th' I is issued(Sec. MICROFILM,
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 6.00
Lender's Name
Lender's AA HEATING UNIT(OVER 100,000B.T.U.0.50 ELECTRIC
I certify Dmt l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information is correct.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP13 H.P.or 100,000 B.T.U.) 6.00
hereby entiorid representatives tarries of (his rpow' x enter upon the BOILER-COMP(0.,100,000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned property for tativinspectionof (h purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against City in Consequence of the
granting Of ns permit. MECH.CONT. LIC.NO.rq, MECH.
r,,tA' � TOTAL
mature of Apphcant/Contractor Date
OFFICE COPY