7268 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
BUILDING PROJECTlDENTIFICATION APPLICATION PERMIT
BDILDING 0 7266
AOOREss
- BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
N""'En/ QTY. ELECTRIC PERMIT FEE
C .10 a4HONE
NAME OUTLETS I UTLETS-SWITCHES-RECEP 5.00/1.00 - 7,
kA uo.D-330 LIGHTING FIXTURES 5.00/1.00 /a S
.ONT cT R'
ADDRESS APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT- SIGNS 6.00 PLAN CHECK FEE P.C.NO.
O
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
ouHH tOn CNG, SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 15.00
APPLICSS
DDREMOTORS SEE FEE SCH. ;
A
SERVICE CHANGE 10.00
wo o LICENSED CONTRACTORS DECLARATION
U I hereby affirm that 1 am licensed order provisions o f Chaplet 9 ISSUANCE DATE
wa y (commencing with Section 7000)of Division 3 of the Business anJ _ BLDG. ELECT. PLG. MECH.
F y z Professions Code,a my license is in full for e ❑ ❑ ❑
z o o- Licrcrgila Lm Number
9 m D Date«' Contractor
A Y s va BUILDING PERMIT
OWNER-BUILDER DECLA ATION INFORMATION
A Oar MISC.- REFER TO ORD
N 3 r I hereby affirm that I am exempt from the Contractor's License VALUATION s $/FT.
F a o 4 Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00 :
wj Code:Any city or county which requires a permit to construct,alter.
7
Q Q ¢ 0 improve,demolish,or repair any structure,pnUr m Its Issuance,also ELEG CONTR. LIC.NO. ELEC. )
C a, ruluires lire opplicam for such-pennit to file a signed statement that TOTAL -PERM
a w m u Ila is licensed purnuanl to the provisions(if the Contractor's License /
Law(Charter 9(commencing will,Section 7000)ol'DivivmF3 oflhe S/SVG -
Busincss and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE E F-
¢ the basis for the alleged exemption.Any violation of$ect ion 7031.5 STORIES (,TYPE CST,R.
by wry applicant.lir a permit subjects the applicant to a civil penally ALTER-DRAIN&VENT-WATER IEA.) 4.00
of not more than live hundred dollars(85081.1:
❑ L as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP f' ,y R s.u r
their sole compensation,will do the work,and the structure is not Igr'
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 \
code:'flm Contractor's License Law does not apply to an owner of J r _
properly who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 4.00 So.FT.FLOOR AREA TOTAL ACREAGE
W-• hinfself or through his own employees,provided that such improve-
mealsare let intended.,.1fered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00 3 (�
or improvement is Sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 ' BUILDING USE
builder will have the burden of proving that he did not build or int- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
D 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct rhe project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
anA Professions Code:The Contractor's License Law does not apply
to a I owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 j;La _ -
conlmcls for such projects with a contractods)licensed pursuant to
the Contract.,',License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
-❑ I am exempt under Sec. .B,&P.C.for this WATER HEATER W/VENT 4.00
rcmvm
Owner Dare WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPI!NSA I ION DECLARATION IWATER TREATING EQUIP. 4.00
1 harehy affirm trial I have a certificate of consent toself-insure, ZONING
or a certificate of Workers'Compensation Insurance,or a cert ifieA ENG.SITE NO.
copyrhereof(Sec.3800,Lab.C.) - /)
Policy Nn. Company
O ❑ Cerli I- d pY is hereby fl hed. FIRE SPRINK ENERGY T-24
Z ❑ Cerrific cl y is led i01� the it ins Ilion divi,cion.
p ApPlicam / MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
w CER A'f1i OP '%E TION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU J COMPF-NSAT NINSURANCE PLG.CONTH. LIC.NO. PLG.
Z (This sec Ion need not be completed if the permit is for one TOTAL V❑ N❑ v❑ N❑
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner So as to
❑ become suhjecl to the Workers'Compensation Laws of Calibarria.
O a Dale-Applicant ALTER OR ADD TO MECH. q-p0 BUILDING po
} m NOTICE '1'O APPLICANT: If,after making this Certificate of lix-
F 2 emption,you should become subject to the Workers Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
(� such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00C.F.M.) 5.00 SEISMIC FEE q-
I hereby affirm that there is a construction lending agency lot EXHAUST HOOD(WITH DUCT) 2.00
the pertormmnce of the work for which this permit is issued(Sea HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3057,CW.C.I.
Lender's NamEAG
e HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Len der',AJdress _ .1
I certify that I have read this application and nate that the above VENTILATION FAN (SINGLE) 3,00
num-nmaion K correct. I core to comply with all city and county PLUMBING
• ordinances and state laws relating to building construction, and
BOILER-COMPI3 H.P.or 100,0008.T.U.) 4.00
hereby aurhorixe representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above mentioned property for inspection purposes,
N (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which ,CONST.TAX
may PERMIT ISSUANCE 3.00
'i any way accrue against said City in consequence of the r�
gr in of this per r . ` MECH.CONT. LIC.NO. MECH.
/ TOTAL TOTAL q a /Q•
L.Y
Si tare ofA tic ontrador Date '
INSPECTOR COPY