C8160 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I PEUTIZACATION
PERMIT NUMBER
ADDRESS
APPLICATION & PERMIT �� b^�
-L ooness
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER' PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
/ PHONE
rcioMERACTORs UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO, LIGHTING FIXTURES 10.00/1.00
ADD RE55 RA R APPLIANCES-RESIDENTIAL 4.00
OD ^
GI
PHONE _ PANELS 10.06 DATE OF APPLICATION
Oq GT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCHE sS ENG. SPECIAL CIRCUIT S.QQ PERMIT VALIDATION
AzIv EMP.METER OR POLE INS. 20.00
ADDRESS r$ MOTORS SEE FEE SCH.
AOORE55
w SERVICE CHANGE 20.00 3�LICENSOCDA /o o ON
TEMP.POLE30.00
S
aw I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
z «
< n (Commencing with Section 7000)of Division 3 of the Business and B 0 ELECT. PLG. MECH.
F N, Professions Code an my license is in full force and effect.
z 0 a �/ License Cl s Lia.Number ❑�
O - o Date Contract., C'y:5 T 60
a m '� V BUILDING PERMIT
¢ ¢ a OWNER-BUILURR DECLARATION
¢o n o INFORMATION
¢ w I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
a, of Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city or county which requires a permit to construct,alter,
¢ ¢ ¢ 0 improve,demolish,or repair any Orneture,prior to its issuance,also ELEC.GONER. LIC.NO. ELEC.
O¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
E
$ he is licensed pursuant to the provisions of rte Contractor's License
rzi
Law(Chapter 9(cummencing with Sect ion 7000)of1)ivision 3 of the �9/ I
a Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE (/E- I
¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 ] RIES TYPE CONSTR.
a ;T by any
..one than
for a permit delta,,the applicant toacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of net n as than five hundred dollars(my employees
❑ 1,as owner at Inc will dot or my employees with regent BACK FLOW PROTECT. DEVICE 4.00 CC. OUP '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 docs not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.Provided that suchinip¢me-
me,nu are not intended or offered for sale,If,however.the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
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 proving that he did not build or im- BUILDING USE
RES
prove for purpose of sale.). IND Pe Ornar
' INDUSTRIAL WASTE INTER. 30.00 ❑ El0 El El
I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project (Sec. 7044,Rosinec' LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESS. 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
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ 1 um exempt under Sec,-,BAPTC.for this WATER HEATER W/VENT 6.00 j
Raitln
Owner Dutra WATER SYSTEM 5.00 ACC.DATE ACG FILE NO.
WORKERS'COMPEN'SA'FION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insue, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certiliLd
copy thereof(Sec.3800,Leb.C.). ,
Policy No. Company
0 ❑� Cy tified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z @/C'erti ' d c py is filed with theity inspection division.
O Applicant //� I MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
2 = / ",ITIF A4.1,F&FMP ,O. pf WORKERS• PERMIT ISSUANCE 10.00 FLooD zoNE A.L.u.c.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PL
LG
(T .
his section need not be completed if the permit is for one TOTA
Z V❑ N❑ V❑ N❑
hundred dollars(S 100)or less.)
0 O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
EL H mit is issued, I shall not employ any person in any roamer so as to -
U become subject to the Workers Compensation Laws of California.
d Dam Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NO1'ICF TO APPLICANT: If,after making this Certificate of Ex-
F Z emplion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U Stell provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONS'I'RUCiION LENDING AGENCY AIR HANDLING UNIT(OVER 10DMC.RM.) 6.00 SEISMIC FEE
I hereby affirm that there is a hick t dice mit is
agency fur EXHAUST HOOD(WITH DUCT) 5.00
the performance of De work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application andstate that the above VENTILATION FAN (SINGLE) 4.00
. information MP
correct I agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction, and 80ILER-CO (3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL
u
(We) agree to save, indemnify and keep he...des, the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
fray in any way accrue against said City in consequence of the
grain tingof his Permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
. na arc of APPlic:m[/ on Ua for rat
INSPECTOR COPY