8131 APPLICANT TO FILL IN INFORMATION WITHIN RED LI S - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION
aD PERMIT NUMBER
L ESS � PLI I & PERMIT
FDD E55
UILDING-ELECTRICAL PLUMBING-MECHANICAL 31
PLAN CHECK VALIDATION
DTV. ELECTRIC PERMIT FEE
" R OUTLETS-SWITCHES-RECEP 10.00/1,00
NAM
C.No. [ LIGHTING FIXTURES 10.00/1.00
r- T Rs PPLIANCES-RESIDENTIAL 4.00
A
_ PRONE PANELS 10,00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
ADOFESS ENGSPECIALCIRCUIT 5,00 PERMIT VALIDATION
tr
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS \ / MOTORS SEE FEE SCH.
A O Ess •}/� /� A ('
SERVICE CHANGE 20.00
C o oy� LICENSIiU CONTRACTORS DIiCLARATI N TEMP.POLE 30.00
a U [j I hereby affirm tint 1 ant licensed under povisions of Chapter ISSUANCE DATE
h ¢ (conunencmg with SccliOn 7000)of Division 3 of the Business J BLDG. ELECT. PLG- ME H.
F n i Vrofcssions Cadc.' 1 my cense is in full force f t-
z o m - License Class
Lie.Number / ❑
_o - Ume ontmctor
w
BUILDING PERMIT
¢ 0 w ¢ N. -B ILDER DECLARATIO INFORMATION
= oau MISC.- REFER TO ORD
X
3 LL h 1 hereby affirm that I am exempt from the Contmclor a License VALUATION SIFT.
H LL o¢ Law for the following reason.(Sec 7031.5,Business and Professions PERMIT ISSUANCE 10.00
CodeAny city or county which requires it permit to cnnslo.L alteq
¢ a improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- D ¢ requires the applicant for such permit to the II signed stm nicut that TOTAL PERMIT TO
u w m w he is licensed pursumit to the provisions of the Contractor's License
Fzi m
Law(Chapter 9(conlencing with Section 7000)of Division3oflhc
¢ Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE \
¢ o the basis for the alleged exemption.Any violation of Section 703LS STORIES TYPE CONTPA.
d am - by any applicant for a peonit sabjecis the applicant(03 civil penalty ALTER-DRAIN III VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employers with wages as BACK FLOW PROTECT. DEVICE 4.00 GCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code, The Contractor's License Law does not apply to an owner of '
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE .
• himself or through his own employers,provided ev such impove-
menisxrenet intended or employee,d for h.provided
that r.suhebuildingmproe- GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion, the owner GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or int- RES IND CON . PB borer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 1
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ +❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs not apply ,
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
unl true is for such p(jects with a amtmetogs)licensed punumd to
the Contractor's License Law. SEWER-SANITARY-STORM EA.2001t/10.00 TRACT NO. PARCEL NO.
❑ I am ezentpt under Sea ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ul consent lu self- sure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation 1 sural e,or a rtified
copy there9fy$ey�3g ( Lab.C.).
I'olicY No.y �flimtpanY
O ❑ eD e alpy shcmby hqq . FIRESPRINK ENERGY 24
z ZO \ ❑ neified en is RI iii 1h• it, inspection division. MISC.- REFER TO ORD. Y N y N
❑ ❑ ❑ ❑
ccw CE c IiO 7'xrM ONFROMw ERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
UJ >_ COMPENSATION INSURANCE PLG.CONTR. LIC.Na. PLG.
0- 0 ('['his section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ No
::) Z hundred dollars IS 100),o less.)
U 0 1 certify that In the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is ivued, I shall not anploy any person in any manner so as to
U become subject to the Workcrs'Compelaation Laws of California.
Lu Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE TO APPLICANT: If,after making this Certific.1 of Ex-
F Z nnption,you should become subject to the Workcrs'L'm,Penaal ion APPLIANCE 5.00 PLAN CHECK
U
provisions
of tfor thisbor Code, you must lilrthwith comply with -M) 4FEE
such ppermit shall be deemed revoked. AIR HANDLING UNIT(TO 1Q000C.F, . 00
CONSTRUE IION LENDING AGENCY R HANDLING UNIT(OVER 10,000C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency forXHAUST HOOD (WITH DUCT) 5.00
tile
3097 Civ.C.)
ence of the work for which this permit is issued(See. HEATING UNIT (TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name
Lendcr's'Nam eATI NG UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
ss H
I certify Rod I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county Z7 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 this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indepwfy and keep harmless the City of MISC.- REFER TO ORD. .
Cupertino against Iiubiliti ,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in•any way ecru again t said City in consequence of the
gra ting of this unit. CH,CONT. LIC.NO. MECH.
TOTAL TOTAL
Si umhm fApplic It/Con c r e
4
INSPECTOR COPY