7266 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER RUILm'GAPPLICATION SPERMIT
ADess BUILDING - ELECTRICAL-PLUMBING -MA
NICALRA/ 0C- 41.JrA 7266
BVNER'S PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE
. o r VAS' S' M PRG 5S
-090 O
LONTRACTOR'S
NAME �� OUTLETS-SWITCHES-RECEP 5.00/1.00
Lc.NO, SO LIGHTING FIXTURES 5.00/1,00
CONTRA
ADDRESS ORs APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.NO SIGNS TRANS. 3.00
ADDRESSARC
ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
z11 EMP.METER OR POLE INS. 15.00
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS
ECLARATION
SERVICE CHANGE 10.00 / J
00 LICENSED CONTRACTORS D
¢ u I 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
Z ca
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT_ PLG. MECH.
rz Professions Code,and my license is in full force and effect. ❑ ❑ F-1
❑
z o m - License Class Lic.Number
g Uatc Commcmr
¢ x f _ BUILDING PERMIT
¢ rc w ¢ OWNERBUILDERDECLARA'PION _
INFORMATION
a o a MISC.- "REFER TQ..ORD
w r 1 hereby affirm that I en exempt from the Contractor's License VALUATION $/FT.
HLL0`� Law for the following reason.(Sec.703,5,Business Professions PERMIT ISSUANCE 6.00' r-
Code:Any city or county which requires a permit to construct,alTeq -O
¢ Ws-Q - improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC_N0. ELEC. ;
n m LL reir
ques the applicant for such perma it to file signed statement that 1 TOTAL �'- PERMIT TO
w he is licensed pursuant to the provisions of the Contractor's Liccnse
P, z5- Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe ��p,P T�'��
Business anti Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
IS I Oo the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not mare than five hundred dollars(S5001)'.
❑ 1,as owner of The property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
intended
compensation,will do the work,and the structure isnot
intended or offered for sale(Sec 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CONIC. 4.00,
Code:'rhe Contractors License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ramtsarenotinleadedorofferedforsule_1,however,The building GAS-EA.SYSTEM-11NC.4OUTLETS 4,00
or improvenment is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or Ira- RES IND CON PB Other
prove for purpose of sale.)- INDUSTRIAL WASTE INTER. 20.00
C11,as owner of We property,anh exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors To construct the project(See 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply to an owner of property ache builds ar improves There., ad who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractor(s)licensed pursmnt To
the C'ontractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT No. PARCEL NO.
Cl I ante exempt under Sec ,11.&P.C_I'or this WATER HEATER W/VENT 4.00 � ..
reason
Owner Date WATER SYSTEM 4.00 ACC!DATE ACC.FILE NO.
E
WORKERS'COMITNSAT ION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that 1 have a c,Hifurte of house"
t1.selfinsure, ZONING
or u itul ficale of Worked Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.3800,Lab.G).
Policy No. - Company
O ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T-24
Z Z ❑ Certilled copy is filed with the city inspection division.
O Applicant MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
CC W OER'I'IPICA'T Ole Ii XEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOODZONE A.L.0 c.
LU > COhIPFNSA'I'ION INSURANCE PLG.COEUR_ LIC.NO. PLG.
CL 0 f This x"tion heed mol he completed if the permit is for one TOTAL Y❑ NE] Y❑ N❑
0-.Z hundred dollars IS 100)uF less.) -
U O 1 certify That in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
U become subject to the Worked Conhpersation Laws of California. Y1
LOT Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING 6� J
} m NOTICE 10 APPLICANT: If,after making this Certificate of 1?x-
Z eruption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK LL Z
provisions of, the Labor Code, you must forthwith comply with FEE -740 --
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10)000QF.M.) 3.00
CONSTR UCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10,000C.F.M.) 5.00 SEISMIC FEE 6-0
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the pedixmmnce of the work for which this permit is issued(Sec. MICROFILM
3097.Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Nameifte )7HEATI NG UN IT ER 100,000 B.T.U. .50 ELECTRIC
I certify that l have read this application and stem Thai the above VENTILATION FAN (SINGLE) 3.00
information is cored. I agree m comply with all city and
manly PLUMBING
ordinances and state laws refuting to buildingconstruction, and BOILER-_OMP
H.Ror100,000B.T.U.) 4.00
hereby authorize representatives of this City m enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above mentioned property for inspection purposes
(We) agree m save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expunses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any they interum against said City in consequence of the
grant ITS of . NOunt. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
a re of A lice / tactor Dale
INSPECTOR COPY i
t