10206 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
BU I LDING PROJECT ID TFICATION PERMIT NUMBER
so ILO Nc
ADDRESS (I MIA PPLICATION & PERMIT
ILpfNG-ELECTRICAL-PLUMBING-MECHANICAL 10206
OWNER'S
NAME PLAN CHECK VALIDATION
1 1 ELECTRIC PERMIT FEE
t-sl- PRo
CONTRACTORS
NAME �� ' UTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CON TRACTORS NCES-RESIDENTIAL 4.00
1x1- <11 Sf
N AN LS 10.00 DATE OF APPLICATION
AORRCN TELT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC,No. SIGNS TRANS. 3,00
ADDRESS ENG' SPECIAL CIRCUIT 5.0Q PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ADDRESS
AMOTORS SEE FEE SCH.
DR
SERVICE CHANGE 20.00
Woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 ! /
<i w 1 hereby affirm that I em IicenseJ under provisi fCB?Rle ISSUANCE DATE
w G (mmmenCing with SeClion 7000)of DIVIaIDn l a BLOC. ELECT. PLG. MECH.
T i Professions de,and my license is in full r a f ❑ ❑ ❑
Z z In o License CI s Con Number
F m s• Dale - Contractor
a m ¢ ¢ OWNER-BUILDER DECLARATI BUILDING PERMIT
K c a u INFORMATION
K
3 u N I hereby affirm-that I am exempt from the Contractor's License MISC.- REFER TO ORD
FuoJ Law for the following reason, 7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION
,A i Code:Any city or county which requires a permit to construct,alter,
2 a, Q O improve,demolish,or repair any structure,prior to its Issuance,also ELEC.CONTR. LIC.NO. SLED,
O u requires the applicant for such permit to fie a signed statement that TOTAL PERMIT TO
F
m he is licensed pursuant to the provisions of the Contractor's License L8
Fi> Law(Chapter 9(commencing with Section 7000)of Division 3 offle
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
EE 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 loa civil penalty ALTER-DRAIN&VENT-WATER (EA:) 5.00
of not mom than five hundred dollars(S500t):
❑ 1,as owner of the properly,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,GOND. 5,00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE
menta are notthrugh intends own emred for sale.
If,ed that however,
the
improve- GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
Improve-
ments are not intended or offered employees,
sale.If,however,(he building -
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 iso- BUILDING USE
prove for purpose of sale.). RES IND CON PB Other
❑ I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ 11
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS FARCE L 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 contractors)licensed pursuant to SEWER-SANITAR V-STORM EA.2001t/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑
reason I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6,00
t
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPF.NSATION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a certificate of consent to 5 -insure, ZONING ENG.SITE NO.
I ace t k tensa 'o n Trance or I
y3 % Y
c an
r he Copy is he byr IFIRE SPRINK ENERGY T 24
Z Z 13Certifie copy is 'led th t icy inspect o div n.
MISC.- REFER TO ORD.
Q Applicant Y N� Y ❑ NC]
CC y PERMIT ISSUANCE 10.00 I
CL - CERT FIC TMPE ION MOM WORKERS' v0O ZONE❑ vA.L❑.U.C.N❑
CL MPENSATION INSURANCE PLG.CONTR. LIC.NO. I.G.P
CL (This sectio ced not he completed if the permit is for one TOTAL
Z hundred dollars(5100)orless)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,1 shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
Q y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
I„- Z emplion,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 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.FM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for 'EXHAUST HOOD (WITH DUCT) 5.00
then performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name
Lender's Address HEATI NG UN IT(CIV ER 100,000 B.T.U.)9.50 ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 1
• information is correct.I agree to comply with all city and county - PLUMBING
ordinances and State laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of (his city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes. -
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. 1
Cupertino ago liabilities,judgments, costs and expenses which CONST.TAX
Ms. in any a accrue against said City in con uence of the PERMIT ISSUANCE 10.00
an'ng of i r i MECH.CONT. LIC.NO. MECH.
/� � _ TOTAL TOTAL '
Si urea i t Cont ct r
OFFICE COPY -