8128 APPLICANT!TO FILL 10 INFORMATION WITHIN ED LINES - USE BALL POINT PEN ONLY f
BU I LDINGPROJECT I DENTIFICATI ON / PERMIT NUMBER
BD,LDING Ltla
CATION & PERMIT
(f FD RE55 811 28
BUILD NG - EL CTR ICAL-PLUMBING-MECHANICAL o
AME / PLAN CHECK VALIDATION
Off/ QTV. ELECTRIC PERMIT FEE
-CON Crops / OUTLETS-SWITCHES-RECEP 10.00/1.00
NAM X
IC.No (J LIGHTING FIXTURES 10.00/1.00
o A T R
ADD E PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 PATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC,No, SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 1 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
Avvuc is MOTORS SEE FEE SCH.
ADD E
SERVICE CHANGE 20oizft�' 4& .00
M o LICENSED CONTRACTORS I :CLARA71oN TEMP.POLE 30.00
Ix o U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
m < - BLDG.with Section 7000)of Division 3 of the Business an BLDG. ELECT. PLG. MECH.
H w z Professions Code and n licenses in full force
z o m - License Class �A_Lit.Nmnber
Q m Fiat on oiclor
¢ m 2 dd ; BUILDING PERMIT
c m ¢ NRR- ILDER DECLA RATI N
O>eJ MISC.- REFER TO ORD INFORMATION
X S I hereby affirm that 1 am exempt from the Contractor's License
LL o ¢ Law for the following reason.(Sec.7031,5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
L- - iA Code:Any city orcounty whichrequiresapenmitto constnmq,a lcq
a ¢ ¢ 0 Improve,demolish,or repair troy structure,prior to its issuance,also ELEC.CONTR. LIG.N0. ELEC.
n wO IY requires the applicant for such permit to Idea signed statement that TOTAL PERMIT TO
$w he is licensed pursuant to the provisions of the Contractor's License
F z a Law(Chapter 9(commencing with Section 7000)of Division 3 oflhe
Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
rc F�-c the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
aim by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($500)Ji
O 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 the work,and the structure is not
intended or offered for sale (Seo. 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 sa FT.FLOOR AREA TOTAL ACREAGE
himself'or through his own employees,provided that such improve-
mt,msare nolintended oroffered for sada if however,the building GAS-EA.SYSTEM-1 INC.40UTLETS 6.00
or improvement is sold within one year of conmplelion,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 inr RES IND CNG PB Omer
prove 1, purposeas owner of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
❑ 1,as owner of the property,am exclusively convecting 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 does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1,00
contracts for such projects with a contracluts)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO..
❑ lain c.ecmpl under Sec.-,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKHRS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby uffirnm that 1 have a ccrtificale ofro sent In self=l 'arc. ZONING ENG.SITE NO.
or n certificate of Worker,'Compensation Insu ice or u mr ified
COPY there
Policy No. mPanY
O ❑q�Certi a copy hereby f niched. FIRE SPRINK ENERGY T 24
z O Apnnified co filet wi the city Inspection division. MISC- REFER TO ORD. v N Y N
((fir ❑ ❑ ❑ ❑
ir ir toCI - PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
- :UIr If hl P'fION I'R M O
W MPEN'SAFION INSURANCE PLG.CONTR. ❑C.NO. PLG.
Z 1'1'his section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N[_]
hundred dollms(S 100)or Ics,T
U O I certify that In the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
ly I- mit is issued,I shall not employ any person in any manner so as to
O W buconm subject to the Workers Compensmion laws of California. BUILDING
D- Dat` Applicant ALTER OR ADD TO MECH. 5.00
} W NOTICE TO APPLICANT': If,after making this Certificate of Ex-
F Z emplion,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this pernmit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00 1
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the partoriance of the work for which this permit is issued(Sec. MICROFILM
3097,CN.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name 'H EATING UNIT(OV ER 100,000 B.T.U.)Lender's'Nadress - ELECTRIC
ff
I ecrtity that I naw read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
• information ie correct. I agree to comply with all city and county PLUMBING
ordinances and slate laws relating to huddling 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 lover ioo.ow BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save. indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabili{ked judgments, costs and expenses which CONST.TAX
may in an wa Sim ainst said City in consequence of the PERMIT ISSUANCE 10.00
grafi ng mer ll pen all. ECH. ONT. LIG NO. MECH.
l TOTAL TOTAL /VU
oPAp icaril/ onlm r U e
INSPECTOR COYY