8218 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT ]DENT]FICATI PERMIT NUMBER
enLOlNc APPLICATION & PER
u
ADORES$
/ (90BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 88
OwrvER'B 0 me
64) PLAN CHECK VALIDATION
rvamE _ _ QTY. ELECTRIC PERMIT FEE
NONE (e
N MERAcroFs LITLEIS
-SWITCHES-RECEP 10.00/1.00
_O Lc.No. - LIGHTING FIXTURES 10.00/1.00
TRA R's ADDRESS PPLIANCES-RESIDENTIAL 4.00
T-I��p
'yaHorvE _ PANELS 10.00
'-S C �."1 DATE OF APPLICATION
ORcmrscT - - PAN ELS (OV ER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH,On ENG r SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
SS
ZIP TEMP.METER OR POLE INS. 20.00
APPLI MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
.woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30100 r
¢ U 1 hereby affirm that 1 an,licensed under provisions of Chapter 9ISSUANCE DATE PI
A m w (commencing with Section 7000)of Division 3 of the Business and
¢ BLD ELECT. PLO. I MECH.
0 ow i Professions Code,and my license is in full force and effect,
o Date
- m G LicenseClass Lia Number�6�G qr"
I E7_ ❑
Date i Contractor
a y BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
o a " MISC.- REFER TO ORD INFORMATION
"w 3 u m I hereby affirm that I am exempt from the Contractor's License VALUATION
.. o a Law for the folhewingreason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 S/FT.
Iw.E Code:Any city or county wllchrequire5apermittoconstruct.alleq
¢ ¢ ¢ O improve,demolish.or repair any structure,prior to its issuance,also ELEC.CONTR% LIC.NO. ELEC.
o¢ requires the applicant for such permit m file a signed statement that TOTAL t PERMIT TO
n w m
U. he is licensed pursuant to the provisions of the Contractor's License _
Hsi
Law(Chapter 9(commenciog with Section 7000)of Division 3 of the 1
at Business and Professions Code)or that he is exempt therefrom wW QTY. PLUMBING PERMIT FEE I
f i o
¢ H $ the basis for the alleged exemption.Any violation of Sectioa 703 L$ v STORIES TYPE CONSTR.
is, ; by any applicant for a permit subjects the applicant to a civil penaltyr
of not more than five hundred dollars(SS00).): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 1,as owner of the property,or my employees with wages as BgC*F'COW 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,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
r. menta aye not hrough
ownemployees.Sprovided that such improve GAS-EA.SYSTEM-I INC-40UTLETS 6.00
mems are not intended or offered for sale If,however.the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM OVER 4 IEA.) 2.00
.builder will have the burden of proem,that he did not build or im - BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RE IND CON PB Other
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,BesinussLAWN 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
for f
contracts such projects with a contractors)licensed pursuant to
the Contractor's for 's License Law,
SEWER-SAN ITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lumexemptunder Sec. ,B.&P.C.forthis WATER HEATER W/VENT 6.00
reason
Owner Dote WATER SYSTEM 5.00 ACGDATE ACC.FILE NO.-
WORK
O-WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconsent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,La b.C.).
Policy•' L Company r IJ
O ❑ IlNcd iopy is hereby fumishcd LI� j RE SPRINK ENERGY T-29
Z Z V ❑ Certified copy is Mad with tlm city inspedmn division. MISC.- REFER TO ORD.
O / Applicant - .. Y ❑ N❑ Y ❑ N❑
j CC to Out t c4 -Ant WORKERS
t PERMIT ISSUANCE 10.00
LU - CERTIFICATE E EXEMPTION I FROM WORKERS' FLOOD ZONE A.L.u.C.
W CUM not
be cora INSURANCE PLG.CONTR. LIC.N0. PLG. Y❑ N❑ Y❑ N❑
n' O (This dollars
need not he completed if the permit is for one TOTAL
Z handrail dollars($100)or Icss.l
u U O 1 certify that in the performance of the work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued, I shell not employ any person in any nmnne, ,,as to
U w become subject to the Workers'Compensation Laws of California. BUILDING
p. Date Applicant ALTER OR ADD TO MECH. 5.00 V
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z emption,you should become subject to the Workers Compensation APPLIANCE 5.00 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=CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
I- I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
Due performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
r . Lender's Name
Lender's AddreHEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
ss
I certify Blau I have man this application and state than the above VENTILATION FAN (SINGLE) 4.00
informal ion.is correct. I agree 10 comply will all city and county PLUMBING
ordinances and state laws relating to building construdiun, and BOILER-COMPI3 H.P.or 100,000 B.T.U.) 6.00
hereby entioed representatives of this city tO enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection puity
(We) agree to save, indemnify and keep hmmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
granting.of this permitMECH.DONT. LIC.NO. MECH.
\\X/` �p 2 y roTAL TOTAL
ran
Store of Applicant/Contractor Uate
42 Zf�
INSPECTOR COPY
t r