8185 4PPLICANT TO FILL IN INFORMATION:WITHIN RED LINES,- USE BALL POINT PEN ONLY
BUI LDING PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION &PERMIT 81 ��
.� ADDRE
LDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER's - - PLAN CHECK VALIDATION
NAME 4.1 OTY: ELECTRIC.PERMIT
G! '
NOrvT A TOR', UTLETS-SWITCHES-RECEP 10.00/1.00 - -
N LIGHTING FIXTURES 10,00/1.00
ACTORS
AsAPPLIANCES-RESIDENTIAL 4.00
ON PANELS 10.00 DATE OF APPLICATION
ARCHI Ec PANELS (OVER 200 AMPI 20.00 PLAN CNECK FEE P.C.NO.
OR
ENGINEER -
uc.N SIGNS TRANS. 3.00 '
ADDR OSE SPECIAL CIRCUIT 5,00 PERMIT VALIDATION -
EMP. METER OR POLE INS. 20.00
ADDRESS
S
A _ MOTORS SEE FEE SCH.
.' � /
SERVICE CHANGE 2400
o o LICENSED CONTRACTORS DECLARATION TEMP.PALE 30.00
Fi w 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE GATE
a (commencing with Section 7000)Of Division 3 of the Busines nd BLDG. ELECT. PLG. MECH.
H N i Professions Cod n 'cense is in full fore t--1
oism o License 'ss Lia Nun.her D( I
2 y r j ,Date_ Contra T
a x s BUILDING PERMIT
¢ a OWNIiR-BUILDIiR DECLA A'fION
E c a v INFORMATION c'
w ; r I hereby affirm omt I am exempt from the Contractor's L' rise MISC.- REFER TO ORD
a.a a Law for the following reason.(See,]031.5.Business and I'r ,,ions VALUATION $/FT.'
Code:Any city or county which re:juiesa permit to cons ct,dle" : PERMIT ISSUANCE 10.00
i
Q . 4O improve, or repair ariy structure,prior to its Dance,also ELEC.CONTR. - LIC:NO. ELEC.
aa O LL requires the applicant for such permit to file'a Signe Intervent that TOTAL PERMIT
w m he is licensed pursuant to the provisions of the C tractor's License
H z.i Law(Chapter 9(commencing with Section 700 Of Division3ofthe '�
f ¢ o Business and Professions Code)or that ho i xempt therefrom and DTV: PLUMBING PERMIT FEE -
¢ 1- the basis for the alleged exemption.Any v ation of Section 7031.5 " - STORIES TYPE CONSTR.
a 3 .2 by any applicant for a permit subjects it applicant to a civil penalty
of not marc than five hundred dollars 5000.1ALTER-DRAIN& VENT-WATER (EA.) 5.00 a -
: -
❑ C as owner of the o try, my employeeswith wages as BACK FLOW PROTECT. DEVICE 4.00 f OCC.GROUP RES.UNITS
sole compensate do t work.and the structure is not
intended or offered o I IS . 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contract L c Caw does not apply to an owner of -
propertywhobuilds imp vesthereon,and who does such work FIXTURES-PER TRAP 5.00 SO.vr.FLOOR AREA-TOTAL ACREAGE
himself or through h ow employees,provided that such improve- _
menrs are not intended offered Or sale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00 `
• or improvement is sol ithin one.year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
.builder will have the urden of proving that he did not build or im-. RES IND CON PB Other
prove for purpose sale.). INDUSTRIAL WASTE INTER. 30.00 .
❑ I,as owner f the property,am exclusively conine ing.with11 0 El 11 11
licensed contra is to construct the project(Sec.7049,Business LAWN SPRINKLERS-1 INC 5 V.B. - 6.00 ASSESSORS PARCEL NO.
and Professin Codi The Contractor's License Law docs not Apply I
to an owne f property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts r such projects with a contractor(5)licensed pursuant to tire Con actor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ is.exempt under Sec. ,B.&P.0-tis this
reasc WATER HEATER W/VENT' 6.00
OW cr Date WATER SYSTEM - 5.00 ACC.DATE ACC.FILE NO.,
- WORKERS'COMPENSAT[ON DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a Certificate.fconsenl to self-insure. ZONING ENG.SITE NO.
or a ceNificate of Workers'C.mpens lion Insurance,or a eerlil'ieA
copy then#(jSecyj_P ( pant' ). -
I'oCiNltjl$TJ_ pony-
❑ Cer I led copy rs hereby furni ed. - FIRE SPRINK ENERGY T-Y4
z (]/C'erf ified copy is pled.with'the city inspection division. '
Applicant MISC.- REFER TO ORF Y N Y C] N(_]
~ h PERMIT ISSUANCE 10.00
M - CER Il FICA'fE OF.EXEMPTION PROM WORM IRS' FLOOD ZONE A.L.u.a,
W COMPENSATION INSURANCE PLG.CONTR. - LIC.NO, PLG, r
CL O (Phis section need not Ibe completed if the perini s for one TOTAL Y E �N Y � N�
D 2 hundred dollars($100)or less:) -
L) O I certify that in the peil'ormance of lire wor' r which this per- OTV MECHANICAL PERMIT FEE FEE SUMMARY
LL I= not is issued,1 shall not eto toy any person' any manners.us to - -
O w become subject to the.W Compens, n Laws of California.
Dale p ALTER OR ADD TO 5.0 BUILDING
} tail NOTICE 1'0 APPI.1 A 7.. ,aft making this Certificate of His-
5
emption,you Shoal ame st ct to the Workem'Compensaiion APPLIANCE 5.00 ' PLAN-CHECK
provisions of the L hor C you most forthwith comply with FEE^
U Z,,
ns or this P It shall be deemed revoked. ]_ AIR HANDLING UNI 1 Cm.; 4.00 +
CO RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) IS SEISMIC FEE
m that there is a construction lending agency for EXHAUST HOOD.( 5.00
thenee of the work for which this permit is issued(Sec. - MICROFILM
. - HEATING UNIT(TO 100,000 B.T.U.) 8.00
� 1 e HEATING UNIT 100,000B.T.U.)9.50
ress ELECTRIC
1 certify that I have read this application and slate that the shove VENTILATION FAN (SINGLE) 4,00
- information n correct. I agree to comply with all city and county - P:70-,e-
hereby
PLUMBING
ordinances and state laws relating to building construction, and 7- BOILER-COMP(3 H.P.or 100,000 B.T.U.)' 6.00 ' �
hereby entio ed representatives
ec this city a elver upon the BOILER-COMP(Over 100.000 STU)SEE FEE SCH. MECHANICAL
hereb dulionud property forinsp ofth i purposes.
(We) agree to.save, indemnify and keep harmless the City of MISC.• REFER TO ORD. -
Cupertino against liabilities,judgments, costs and expanses which PERMIT ISSUANCE': CONST.TAX
S may in any wa ccrue agai t said Ci ly in Conse enee f the -
granting O(lh a 1. ME .CONT. LIC.NO. - MECH.
Signa p n, ac r ate
a WAd�� TOTALTOTAL .
F CE COPY '