8819 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BU LDING PROJECT I DENTI FICATI ON PERMIT NUMBER
tA
A LDISDREG APPLICATION & PERMITSS
8819
O P �L�P BUILDING —ELECTRICAL—PLUMBING—MECHANICAL
OWNER'S
NAME PLAN CHECK VALIDATION
r QTY. ELECTRIC PERMIT FEE
Sr PHONE
NgMERAcroRs OUTLETS-SWITCHES-PIECED 10.00/1.00
T /aG IM10 uc.NoJW'71-* LIGHTING FIXTURES 10.00/1.00
AOORESSTORS _.�I PPLIANCES-RESIDENTIAL 4.00
S 7Q W1114041i4(/E PHONE2��-!may PANELS 10.00 PATE OF APPLICATION
onnCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION I
zlv ITEMP.METER OR POLE INS. 20.00 _J
ADDRESSTa MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
In M W o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
Q U w I hereby affirm that I am licensed under provisions Of Chapter 9 ISSUANCE DATE
aa,G a. (Commencing with Section 7000)of Division 3 of the Business andBLDG. ELECT. PLG. MECH.
0 m i Professions Code, I license is in full fore ysl �,. ❑ ❑ ❑m C License Class Lic.Numf �pfL�
9 y r w Date_ �fo��Contractor_�es r� El
Q Y J BUILDING PERMIT
a m w OWNER-BUILDER DECLARATION
m0 LL H 1 hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD INFORMATION
a, w o J Law for he following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
0 Code:Any city or county whichrequiresa permit toconslruct,a0eq
Q at ¢O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTH. LIC.NO. ELEC.
Ic a O LL !enures the applicant for such permit l0 file a signed statenicrit that TOTAL PERMIT TO
w m he is licensed pursuant to the provisions of the Contractor's License sv
FZi
Law(chapter 9(commencing with Section 7000)of Division 3 ofthe fL6 G,
E z o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
X F g the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant ton civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ 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 SD.FT.FLOOR AREA TOTALACREAGE
• himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.40 TS 6.00
or improvement is Sold within one year of completion, the owner- M 1 2
builder will have the burden of proving that he did not build or im GAS-EA.SYSTE -OV EA. 2.90 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 1 Q RES IND CON PB Omar
❑ I,as owner of the property,am exclusively contracting with 0 0 0 0 ❑
licensed contractors to construct the project IS".7044,Business LAWN SPRINKLERS- .B. 6.0 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not: apply
to an owner of property who builds or improves thercon.and who LAWN SPRINKLERS-OVER 5( Q
contracts for such projects with a Contractor(s)licensed pursuant to SEWER-SAN V-STO OOf11/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec..,B&RC.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.60 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSAI'ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofensen t Io selM1insom,
or a certificate of Workers'Compensation Insurance,Or a cerci ficd ZONING ENG.SITE NO.
copy thereof(Sec.38Co pang ). w
Policy ere Company
Q ❑ Certified copy Is hereby furnished. FIRE BPRINK ENERGY T-24
z Z ❑ Certified copy is filed with the city inspection division,
p O Applicant MISC.- REFER TO ORD. Y❑ No
❑Y No
CCL CERTIFICATEOPEXEMPTION FROM WORKERS' PERMIT ISSUANCE 10,0�0y'l0 FLOOD ZONE A.L.U.C.
NSZION
Ql , (This section needn1ot be completed Rif hehpermit is far one PLG.LDNTR, LIC.NO. TOTAL V �W Y❑ N C] Y❑ N�
CL o
:� Z hundred dollars($100)or less.)
U O 1 certily that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issueQQ I s all not employ any person in al y manner so as to
} U bee he he Wlicant' She}yul e W fC'I rnia.
U DO Date— Applicant_after
mrRf ALTER OR ADD TO MECH. 5.00 BUILDING
DO NOTICI:T APPLICANT: If,after m' m this Certificate of Gx-
? emption,you should become subject m 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 110=1C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that here is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read his application and stale that the above VENTILATION FAN (SINGLE) 4.00
inlbrmation is correct.1 agree to comply with all city and county
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
hereby authorize representatives ins inspection
city es enter upon the BOILER-COMP Inver 1100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property forinsp of this
purposes.
(We) agree to save, indemnify and keep rural 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 a ainst sa'I City in consequcir of the
granting per uL) / MECH.CONT. LIC.NO. MECH.
/ TOTAL TOTAL
Lo 33t ala
SlgnSmlLYot A h �
canl/Contractor Ua�
OFFICE COPY