8129 APPLICANT TO FILL IN INFORMATION WIT IN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NGPROJECT I DENTI FIC TION PERMIT NUMBER
7 ADPPLICATION & PERMIT
DRESS
B66 I G ELECTRICAL-PLUMBING-MECHANICAL 8129
Donlan':i (' I IF I PLAN CHECK VALIDATION
QTY. ELECTRIC PERMIT FEE
T oRs
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
y J CNO. - LIGHTING FIXTURES 10.00/1.00
no tuns PPLIANCES-RESIDENTIAL 4.00
AO E
vEON PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
Llc.NO. SIGNS TRANS. 3.00
ARCH,OR ENO. SPECIAL CIRCUIT 5,00 PERMIT VALI DATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 20.00
APP c rs MOTORS SEE FEE SCH. /y /
ao s
SERVICE CHANGE 20.00
, 02 LICEh'SEU CONTRACTORS DECLARATION
TEMP.POLE 30.00
M o u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
N a u (commencing with Section 7000)of Division 3 of the Business nd BLDG. ELECT. DLG. ECH.
F w i .rofessians Co a0d license is in full fore 1. ❑ ❑ /
a O m - license Class Lie Number 01
O Date Contractor
a r f BUILDING PERMIT
¢ ¢ w a wN. - UILDfiR DIiCLAR INFORMATION
Er MISC.- REFER TO OR
w ; u N I hereby affirm that I am exempt from the Contractor's License / V`LUgT10N 5/FT. .
F .. O j Law for the following reason[Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00' V/� J
Code:Any city or county which requires a permit to construct,alter,
¢ O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
-O¢ requi¢s the applicant for such permit to file a signed FLdement that TOTAL PE IT TO
A w m m he is licensed pursuant tD the provisions of the Conmmtor's License
La V Law(Chapter 9(commencing with Section 7000)of Division 3 of the
4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ o the basis for the alleged exemption.Any violation of Saetion 7031.5 STO IES P C TR.
ate _ by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more titan five hundred dollars(S500).):
❑ 1,as owner of the property,or my employees with wages as BACK F LOW 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,AR EA,COND. 5.00
Code The Contractor's License haw does not apply to an owner of
property who builds Cat improves thereon.and who does such work FIXTURES-PER TRAP 5.00 So.FT.FLOOR AREA TOTAL ACREAGE
• himself re through his own employees,provided that such intProve-
menus o notintendedor offered employees,
or provided that s,the building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Nosiness LAWN SPRINKLERS-1 INC 5 V.8. 6.00 ASSESSORS PARCEL NO.
and Profession..Code:The Contractor's License Law docs nut apply
to an owner of property who builds or improves fhemon.and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
commas fprojects with amuc
ntrlartsl license.)pursuant to
the Contractor'sctor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&I'.C.nbr this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DEC Ll ATION WATER TREATING EQUIP. 5.00
I hereby al'finn that I have u certificate of am raft la self ins[re, ZONING ENGSITENO.
or a certificate of Workers'Compensation hular Ice,o u Fer,, ed
copy there f 3 00,Lab.C.).
Paliy l N 0.L any
O Cer re hereby famished. FIRESPRINK ENERGY T 24
FZ-' ZO plicJn`ified cap 's filed I the y spection division. MISC.- REFER TO ORD. Y ❑ N v N
❑ ❑ ❑
w - 7 PERMIT ISSUANCE 10.00
LU CIiR Ii OF'f: Eh1('T'10• FRO WO FLOOOZONE A.L.UC.
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL a (This section need not be completed if the permit is for one TOT L Y E] N❑ V E] N❑
Z) Z hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued;I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
y Date ApplicamALTER OR ADD TO MECH. IF 5.00 BUILDING -
} In NOTICE TO APPLICANT: If,after making this Certificate of Ex-
Z_ c,option,you should become subject to the Workeri Compensallon APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you 1111151 forthwith comply with FEE
U such provisions m this permit shall be demncd revoked. AIR HANDLING UNIT(TO 10)000C.F.M.) 4.00
CONSTRUC710N LENDING AGENCY AIR HANDLING UNIT(OVER lOfMC.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for XHAUST HOOD(WITH DUCT) 5.00
3097,Civ.0)nee of the work for which this permit is issue.)(See. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name
:iiLender's AJArHEATING UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
ess
I certify that[),a,,read thisapidamium and stun,that the above VENTILATION FAN (SINGLE) 4.00
• infonnalicn is correct. I agree to comply with all city and county 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, indemn'y and keep ham1l,Ss Due City of MISC.- REFER TO ORD.
Cupertino against liabilities sed menus, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any fceree gain said City in consequence of the
Brun n of 11 s nnih MEC .CONT. LIF N0. MECH.
i TOTAL TOTAL
4a App I t/Co tract to
INSPECTO C PY
I