10025 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
, BUILDING PROJECT 1 DENT(FICATION PERMIT NUMBER
BUIL„Np APPLICATION & PERMIT
, E55 FICA
1 /L✓�/PA DO 0R,• BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 1 0 O 2
OWNER'S PLAN CHECK VALIDATION
NAME /J OTV. ELECTRIC PERMIT FEE
/L✓4.�a �O PHONE
NAME"cro�fns UTLETS-SWITCHES-RECEP 10.00/1.00
L ��
f o
'` a / -Ti LL LlC.NO,r7/-t E"2' LIGHTING FIXTURES 10.00/1.00 Nal' 17. e
ADDRESS TORS 1 APPLIANCES-RESIDENTIAL 4.00 V _ ! �A85
//y/ JAA LAN eA/?4o3rCNE;J6-3// PANELS 10.00 D F CATION
OA PANELSPANELS (OVER 200 AMP) 20.00 PEA NC E a.
NGINEER
LIC.NO, SIGNS TRANS. 3.00
ARCH OR ENG SPECIALCIRCUIT 5,00 PERMIT VALIDATION
DRESS
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS
ADDRESS MOTORS SEE FEE SCH. /� /
SERVICE CHANGE 20.00 l/ IL(
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
av I lo,Rby affirm that 1 am licensed under provisionsof Chapter
2 w '( ISSUANCE DATE
m a y (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG.( M H.
H y z Professions Code,and my licence is in full force and effect El ❑ El2 o m
� - License Class Lie.Number
O _ w DateContractor
-H ,
a y E J
c 2 w a OWNER-BUILDER DECLARATION BUILDING PERMIT
F. O' " MISC.- REFER TO ORD INFORMATION
X g LL H 1 hereby affirm that I um exempt from Orn Contractor's License VALUATIOry
LL o a Law for the following reason.(Sec.7031.5,Business and Professions $/FT.
H - Jichrequires PERMIT ISSUANCE 10.00
,A r Code: e.dem y demolish,
coun pair any structure,p rmiLto construct,e,also
Q improve,demolish,ur repair any structure,prior to its issuance,also ELEC.DDNTR, LIC.NO. ELEG.
u
requires the applicant for such permit to file a signed statement that TOTAL
e m he is licensed pursuant to the provisions of the Contractors License MIT TO
or Law(Chapter 9(conimencing with Section 7000)of Division 3 of `/1/(�r/�`
Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
¢ ,- ca the basis for the alleged exemption.Any violation of Section 7031.$ STORIES TYPE CONSTR.
aim by any applicant for a permit subjects the applicant too civil penally ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as ggCK F LOW PROTECTDEV ICE 400
their sole compensation,will do the work,and the structure is not . . OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and ProfessionsDRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Coutmclor's License Law does nol 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 TOTAL ACREAGE
himself or through his own employees.provided that such improve
ments are not intended or offered for sale.If,however,tire building GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement,s 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 int- BUILDING USE
prove finis owner of sale.p RES INDUSTRIAL WASTE INTER. 30.00 IND
❑ PEI❑ Other❑
❑ 1.d as owner of the property,he exclusively contracting with ff
licensed contractors m construct the project(Sec 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESS S RCELNO.
to Professions Code The Contractor's License Law Joos nm apply
to anowner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contruclortsl licerocd pursuant to
the Contractor's License SEWER-SANITARY-STORM EA.200ft/10.00 TRACT O. PARCEL NO.
❑ lam exempt under SSec,eo. ,e.&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER-SYSTEM5.00
ACC.DATE ACC.FILE N0.
WORK ERS'COMPENSATION UECLA RATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consem to self-in sure,
or a certificate of Wurkem'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy lhereof(Sce.3800,I.A.C.).
Policy No. Company
O C1Certified copy is hereby furnished.
Z Z fT�Cy rtifice py fled with th City inspection division. FIRE SPRWK ENERGY T 14
O pplicanT MISC.- REFER TO ORD. Y[] NEI V ❑ N�
ir N TIFICAI'EOF EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOOZONE A.Lu.c.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLC.
CL O (phis section need not be completed if the permit is for one TOTAL Y❑ N[ V N�
� Z hundred dollars IS 100)or less)
L) O I certify that in the performance of the work for which this per. OTV MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit 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 Dole Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} t4 NOTICE TO APPLICANT: IL after making this Certificate of Ex-
Z_ emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply will, FEE
CJ such provisions or this peril shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.0
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT 10=C.EM.) 6.00 SEISMIC FEE
I hereby affix 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.
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.19.50 ELECTRIC
I certify that I have read this application and state that Ole above VENTILATION FAN (SINGLE) 4.00
1nl"^nation is correct 1 agree to comply with all city and countyPLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.DI'100,000B,T.U.) 6.00
hereby authorize rc presentatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH.
above mentioned property for inspection purposes. !CONST.
HANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 Oanti Ofill permit. MECH.CONT, LIC.NO. MECH.
TOTAL OTAL
SlgnalusLFi/1 Appllnant/Contractor I' DID,
OFFICE COPY