C8581 APPLICANT TO FI L IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJEC 1IDENTIFICATION PERMIT NUMBER BUILDING APPLICATION & PERMIT
Y nDDRESDaESS G
2 � O �� -L BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
10 '9581
OWNER'S , HECK VALIDATION
.NAME OTY. ELECTRIC PERMIT FEE
�.1 PHONE
NAIVE roRS OUTLETS-SWITCHES-RECEP 10.00/1.00
v
Q uc.Na. LIGHTING FIXTURES 10.00/1.00
1 I
I;0IaTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS
9v94X2 PANELS 10.00 DATE OF APPLICATION
AOR rrscr PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.c.No.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH,OR
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
APPLICANT s ZIP EMP.METER OR POLE INS. 20.00
aDDADR ESS
ss MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
° ¢ EMP.POLE 30.00
r O O LICENSED COCONTRAC'IURS UL'CLARA'fION
a v I hereby affirm that I run limnwd under provisions of Chapter 9 ISSUANCE DATE
w (mnuncncing with Section 7000)of Division 3 of the Business and
BLD ELECT. PLG. MECH. ]
H o i Professions Code,and my license is In full force and effect. El ❑
o i ih,� License Class &I 6CA4 Lie.Number
H Date �.'-1-Y� Contractors - ,
BUILDING'PERMIT
¢ ¢ a
OWNER-BUILDER DECLARATION
0 0 INFORMATION
X
; n w I hereby affirm that I am exempt from the Contractor's s License MISC.- REFER TO ORD
e_ °a Law for the following reason.(Sec.7031.5,Besinessand Professions PERMIT ISSUANCE 10.00 va LUATION $/FT.
r _ Code:Any city orcountywhich reyuiresapermit toconstruct,alter, �Oov
¢ ¢ ¢ 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
OLL requires the applicant for such Pemt it to l ilhasigned Statement that TOTAL PERMIT TO
e. w m bu is licensed pursuant t0 the provisions of the Contractor's License
Hii Law(Chapter 9(commencing with Section 7000)of Division 30ftle
i %1
a liusincsx and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE Q
°
¢ H m the basis for the alleged exemption.Any violation o(Sed ion 7031.51 STORIES TYPE CONSTR,
ate _ by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five handred dollars(S500).1'.
❑ 1,as owner of the property;or my employees with wages as BACK FLOW PROTECTDEVICE 4.00
their sole compensation,will do the work,and the structure is not . OCC.GROUP RES.UNITS
intended or offered for In (Sha 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:'rhe 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 50,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
Lnts are not intended or offered for sale.IC however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
jmprovement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 (EA.) 200
adder will have the burden of proving that h - . - . .
e did not build or am- BUILDING USE -.
htt)vh for purpose of sale'). INDUSTRIAL WASTE INTER. 3000 E5 IND CON PBS Other
m .
s
❑ 1,as owner of the properly,uexclusively contracting with ❑ ❑ ❑ ❑
liccnscd contractors to construct the project(Sec. 7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law dues not apply
m:ot owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
mtracts l' such projects with a contractors)licensed pursuant to SEWER-SAN V-STORM EA.2001t/10.00
tire or
re ConlmclorS License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-.B&P,C,for this WATER HEATER W/VENT 6.00
reason
OwnerI Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate olconsent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(See 3800,Lob.C.).
t
Policy N, Coppanr ,
O ❑ Cern ed cop Is cretin fun µµd t FIRE SPRINK ENERGY T 24
Z 2 �r� Cer di'd y i lilac y' Ivr city` nspen(ion Division. MISC.- REFER TO ORD.
Q AjsTiliuud i V ❑ NE] Y [:] N❑
sCER'rIPICA rE0 F EX 17611']I(1its p hold WO R K ER S' PERMIT ISSUANCE 10.00 G FLOODZONE A.L.U.C.
LL > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. / Y❑ N❑ Y E] N❑
1 n ('Phis section reed*not be completed it the permit is for one TOTAL
Z hundred dollars(S 100)or less.)
U O 1 Certily that in the performance of the work for which this per- FEE SUMMARY
LL U mit is issued.I shall not employ any person in any manner s,as to DTV. MECHANICAL PERMIT FEE
O w become subject to the Workers'Compensation Laws of California. -
a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
Z tZ
entption,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 he deemed revoked AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby ulfinn that there is u con0nuction]ending agency for EXHAUST HOOD(WITH DUCT) 5.00 -.
the perfonnmice 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 state that the above VENTILATION FAN (SINGLE) 4.00
stminformation is correct. I agree to comply with all city and county PLUMBING -
anees and state laws relating to building construction. and BOILER-COIvlP 13 H.P.or 100,0008.T.U.) 6.00
i;-mentioned property for inspection
auOf tes purposes.
authorize representatives ec this city enter upon the BOILER-COMP (Over,100,000 BTU)SEE FEE SCH. MECHANICAL
2Wu) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
gr u y way,aw against said m consequence of the
prarun o this perm MECH.CONT. LIG NO. MECH.
�y , S � ��
TOTAL TOTAL
Sign i rs,o pp,"cant t uL or Date
INSPECTOR COPY
Is )