8149 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
_
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
ADDRESS ADDRENGZzl'FS /7�G.���T /�Q APPLICATION & PERMIT
. 0 /�
BUILDING-ELECTRICAL-PLUMBING -MECHANICAL (� 4
._- . 19
OWNER'S + PLAN CHECK VALIDATION
NAME ' QTY. ELECTRIC PERMIT FEE
• n. �C,G n PHONE l
CONTRAC�jOqq,rS
n NAME {.,+'tSTF<L/NO .,EL��-�� G .>�-- OUTLETS-SWITCHES-RECEp 10,(P/1.00 S'
(� LIGHTING FIXTURES - 10.00/1.00
-� CONTRACTORS +' L5AN ,G12L1 VU APPLIANCES-RESIDENTIAL 4.00 '
ADDRESS pp
LIH PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECTOPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE V.C.ND.
ENGINEER -.
uc.NO. SIGNSTRANS. " 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS �- SPECIAL CIRCUIT 5.00 Q '�
AZIP EMP.METER OR POLE INS. 20.00
ADDRESS 2 �
- MOTORS - - SEE FEE SCH.
ADDRESS
SERVICE CHANG 20,00 3/���5/
0 0 0 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
ri W I hereby affirm that I am licensed under provisions ol'Clmpter 9 ISSUANCE DATE
< u fcomme icing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r y'^ Professions Code and m license is in full fore ff t S
o m - License, ss Lic.Number
z CoP 0 ❑ ❑ ❑ ❑
D Z Date Cnntractar',9f �� Q1t\S\
CAI BUILDING PERMIT
¢ IS wa OWNER.BUILDER DECLARA'T'ION
G INFORMATION
E
;LL m I hereby affirm that I am exempt from the Comractor's License MISC.- REFER TO ORD
:. O j Law for the following reason.(Sec.7031.5,Business and Professions VALUATION $/FT.
- PERMIT ISSUANCE - 10.00
Code:Any city or eamily which requires:[permit to construct,alter,'
QQ Q 0 improve.demolish,Or repair any Structure,prior to its Issuance,also ELEC.CONTR. LIC.NO. ELEC. �E `
D¢ requires the applicant for such permit to file a signed statement(bat TOTAL V_ PERMIT TO
X$ he is licensed pursuant to the provisions of the Contractor's License
Zi Law(Chapter 9(commencing with Section 7000)ofDivision 3of[lie ELGK .
x o Business and Professions Code)or that he isexcmpt therefrom and CITY. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a by any applicant for a permit Subjects the applicant tua civil penalty ALTER-DRAIN (EA.) 5.00
of not more than five hundred dollars(55000.): -
❑ 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 Ole 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 loam 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 thio Ugh his own employees.Provided that such lmprove-
mentsarenot intended oroffered for sale,If,however,the building GAS-'EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4'(EA.) 2.00
builder will have the burden of proving that he did not build or im- . BUILDING USE
prove for purpose of sale.). - RES IND CON PB Other
❑. I,as owner of the properly,am exclusively contracting with INDUSTRIAL WASTE INTER. ,30.00 D EJ CD El
licensed Contractors to construm the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License L,w does not.,Py
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts forsuch projectswillia contractogs)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. - -TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date - WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK E RS'CONIPF:NSATION DECLARATION WATER TREATING EQUIP. 5.00
[.hereby affirm that 1 have a certificate of consent to self-in sora, ZONING ora certificate of Workers'Compensation Insurance,or a certil ted - ENG.SITE NO,
copy thereof(Sec.3800,Lab C.L ,
policy N0.1'cb11VJ Company ST E FUND
❑ Certified copy is hereby mulish
FIRE SPRINK ENERGY T 24
z- ❑ Certified copy d I 1 inspection division.
Applicant � - - MISC.- REFER TO ORD. Y N 0 Y 13 NC]
i y C17RTIFICATI:OF EXBMPI70N PROM WORKERS' PERMIT ISSUANCE 10.00 FLODOZONE A.L.U.D.
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO, PLG, '
t Z (This section need not be completed if Om'permit is for one' TOTAL Y N❑ Y ❑' N
hundrdedollars IS 100)or less.)
U O 1 certify that to the performance,of the work for which this per, OTY, MECHANICAL PERMIT FEE FEE SUMMARY
.LL I- mit is issued,I shat[not employ any person in any nsnnner so us to
Q w become subject to the Workers'Compensation Laws ofCalifornia:
Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} SO NOTICE '1'O APPLICANT: If,after making this Certificate of E.-
Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
C„) such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 16=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=1C.F.M.) 6.00 SEISMIC FEE
I hereby affirm 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. MICROFILM'
3097,Civ.C.). HEATING UNIT TO 100,000 B.T.U.) 8.00
Lenders Name HEATING UNIT(OV ER 100,000 B.T.U.)9.50 �a
Lender's Address ELECTRIC
I certify III at'I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
•� ordinances n correct I agree to comply with al[City and county PLUMBING
ordinances and orate laws relining to building construction, and - BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize rePoncoatives of this city to enter upon the BOILER-COMP [Over 100,000 BTU)SEE FEE$CH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino againse
ies,jud is is:sed expenses which' PERMIT ISSUANCE. 10.00CONST..TAX
may in any way gai t sa Ci[y I onsequence'of thegrantingol[his MECH.CONT. LIC.NO., MECH. -
OTAL TOTAL
Ignalure o Applicant/C(Muller., "•Dale
OFFICE COPY -
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