8133 /) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
1V/y" BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING / LIGATION & PERMIT 81 ��
AOORCSS
U LDING- ECTRICAL-PLUMBING -MECHANICAL
RS / PLANCHECK VALIDATION
NnME _ QTY. ELECTRIC PERMIT FEE
'c N IA s UTLETS-SWITCHES-,RECEP 10.00/1.00
NA
Lc.No LIGHTING FIXTURES 10.00/1.00
:O ACTOR APPLIANCES-RESIDENTIAL 4.00
A
PHON PANELS 10.00 DATE OF APPLICATION :
RCHRE
C PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
' LIC.No. SIGNS TRANS. 3.00
ARCH,OR ENG. PERMIT VALIDATION
AD0HESS SPECIAL CIRCUIT 5.00
ZIP EMP.METER OR POLE INS. 20.00
APPLI ANTS l MOTORS SEE FEE SCH.
Aoo €s J
SERVICE CHANGE 20.00 kr
woo LICENSIiU CON'I'RACI'URS 1 ECLARATION TEMP.POLE 30.00
u u I hereby affirm that 1 am licensed under provisions of Chapicr ISSUANCE DATE
hG u Icommemm�g with$e<tion 7000)of Division 3 of the Business at BLDG. ELECT. PLG. EC
F w i Professions Codc d I license is m full force a def 1 ❑ ❑
z 0 m - License Class_ Lic.Number
O r Dare Contractor
P y s ��` BUILDING PERMIT
w ¢ N R- ILDER.DIiCLARATI INFORMATION
a o a REFER TO ORD
w 3 LL y I hereby affirm that I am exempt from the Contractor's License MISC.-
VALUATION $/FT.
LLoa Law for tire following reason.(Sec.7iresa permit
to construct,
Professions PERMIT ISSUANCE 10.00
Cade:Any city or county which requirse Penni[toconstruct,,also
¢ ¢ inlpnrvc,demolish,or repair any slnmturc,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC.
- O u requires ilia applicanl for such permit to Glc a signed smtcmanl Ilial TOTAL PE IT TO
A w m he is licensed pursuant to the provisions of ilia Contractor's License
F z i
Law(Chapter 9(commencing with Section 7000)of Division 3 of ilia
¢ 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 Section 7031.5 STORIES E CONSTR.
dam by any applicant for a permit subjects the applicant to a civil penalty gLTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(S500).):
❑ 1,as owner of the properly,or my employees with wages as BACK F LOW PROTECT.DEV ICE 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,AREA,COND. 5.00
Code:'rhe Contractor's License Law does not apply to an owner of
property who builds or improves thereat.and who does such work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR A REA TOTAL ACREAGE
himself or Got hrough
own unployffeed fors, le.If,ed ever,such improve- GAS-EA.SYSTEM-1 6.00
_tants are not intended or ol'feand for ante.If, mpleveq the building
ur improvement is sold den o one year cl that
lie completion, the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving(hal he did not build 0r int- RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ Las owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct ilia 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 forsuch projectswith a contractods)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law, TRACT NO. PARCEL NO.
❑ l um exempt under Sec.-.T&P.C.for this WATER HEATER W/VENT 6.00
le"Inl
Owner Date WATER SYSTEM 5.00
ACC.GATE ACC.FILE N0.
WORKERS'COMPENSn'1ION DECLARATION WATER TREATING EQUIP. 5.00
I hcrcby affirm that I have a ccrtificme of cm sent to self it Inc. ZONING
or a certificate of Workers'CompvmahHH Insurance,or a car if fail .ENG.SITE NO.
copy Ihemof 3 00,Lab.CJ.
p
Policy No omRany
O rt' is heby for II L
d. FIRE SPRINK ENERGY 24
z zeridw `J co y filed sdt the Ity inspection division. REFER REFER TO ORD.
0 1 ❑
/q�P'y',f`nt MISC. v ❑ N❑ Y ❑ N
H CER�141C .OF IS UPTI7P 01450 PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.0
LU C MPF;NSA I ION INSURANCE PLG.CONTR. LIC.NO. PLG. YE] NE] v ❑ NE]
C1 (This section need not be completed if the permit is for one TOTAL
hundred dollars($100)or less.)
U O 1 certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
11 F mil in issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
W Date nppiicunt ALTER OR ADD TO MECH. 5.00 BUILDING
} Go NOTICI; TO APPLICANT If,after making this Certifimcate of fix
f- z emption,you should become subject to the Workers'copensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
CJ such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE'
I hereby affirm that there is a comtructi0o lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(See. MICROFILM
3097,Civ.C.). HEATING UNIT ITO 100,000 B.T.U.) 8.00
Lender's Name HEATI NG UN IT(OVER 100,000 B.T.U.19.50 ELECTRIC
Lender's Address
I certify that l have read this application and state tltat the above VENTILATION FAN (SINGLE) '4.00
ink rrnation n cstatel I agree to comply wish all city and cewlly PLUMBING
ordinances and state laws relining 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 100,000BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indel and keep harmless the City of MISC.- REFER TO ORD.
Cupertino againsr bililie Iud _ants, costs and expenses which CONST.TAX
may in any Xay ccrue Gain vid City in consequence of the PERMIT ISSUANCE 10.00
granng o( h _nil. .CONT. LIC.NO. MECH.
TOTAL TOTAL
grant of Applicant/Con Udctor41-
INSPECTOR COPY
I