8652 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
AGO Ess APPLICATION & PERMIT 8652
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
mR PLAN CHECK VALIDATION
.
' NAME
h'2 If
QTV. ELECTRIC PERMIT FEE
/r C ij PNON
NAM[RacrD 's UTLETS-SWITCHES-RECEP 10.00/1.00
peas v r ID.No LIGHTING FIXTURES 10.00/1.00
ADDRESS
CONTRACTOR
•'� M co 'A�e 41 PPLIANCES-RESIDENTIAL 4.00
7 NG.t3�'n Q+�rls�
P NE PANELS 10.00 DATE OF APPLICATION
AR mTE • PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC,NO SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS SPECIALCIRCUIT 5.00
ZIP TEMP.METER OR POLE INS. 20.00
Ars
ADDRESS MOTORS SEE FEE SCH.
oREss
SERVICE CHANGE 20.00
, 02
0o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a D,U 1 hereby affirm that I am licensed under provisiolis of Chapter 9 ISSUANCE DATE
N z w (commencing with Section 7000)of Division 3 of the Business and
H BLDG. ELECT. PLG. MECH.
F to z Profcsnons Code, nd my license is in full fore and cffcd.
z o w- License Class�_Lia Number ❑ 101 ❑ ❑
9 z I_ _ Dalc Contractor -
P e,M �� IL' •�'T' BUILDING PERMIT
¢o n OWNER-BUILDER UECLA RATION INFORMATION
wg a- w I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
HLLOj I.aw fur the followingreasoo.(Scc.7031.5.Businessand Profcsalons - PERMIT ISSUANCE 70.00 VALUATION $/FT.
Code:Any chy or county which requires x permit to construct,alteq 7`GI GOV
IC improve,demolish,or repair any structure,prior On its issuance,also ELEC.CONTH. LIC.NQ' ELEC. "
u K m u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of lire Contractor's License
z i Law(Chapter 9(commencing with Section 7000)o(Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE //V T >�� 6 a 6 L H
E z O the basis for the aIle exemption.An
RHo ed tion.g• p the
o to a cion malty STORIES TYPE CONSTR.
i ; by any opplicIra for a permil delta,,the O).): ant tau civil
penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred Dollars(5500).):
❑ 1,as owner of lire property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole cmnpenmtion,will do lire 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
A
A properly who builds or improves thereon,and who dues such work FIXTURES-PER TRAP 5.00 so.FT FLOOR AREA TOTAL-ACREAGE
himself or through his own employees,provided that such int prova.
meets 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 OC completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or
int. BUILDING USE
prove fur purpose ofsale.). INDUSTRIAL WASTE INTER3000 RES IND CON PB Omer
❑ I,as owner,of the property,an exclusively contracting with . .
❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-I 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 contmctons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Cmltracloi s License Law. TRACT NO. PARCEL NO.
❑ lam Cxnnpl under Scc. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORK E RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby athrin that I have a certificate of consent to selGinsam, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance.or a certified
- 'copy thereof(See.3800,Lab.C.).
I Policy N'o. Conn..any I• /J• ..144 i' fill .
❑ Certified copy is hereby(touishi �I•/LDS/�1� FIRE SPRINKi ENERGY T2A-
ti ' is fiICJ lir C city insPect100n-division.
Z z MISC.- REFER TO ORD.
O APplicau v ElN E] v ❑ N[]
~ ti PERMIT ISSUANCE 10.00
� - ER I P ICA'I'h OF E%fi,y ION FROM WORKERS' FLOOD ZONE A.L.U.C,
LU COMPENSAffON INSURANCE PLG.CONTR. LIG NO. PLG. V❑ 'N❑ V❑ N❑
CL 0 (This section need not be completed if the permit is for one TOTAL
D Z Imndredd,dars(SIBO)orlCss.) .
V O I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued, I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Lows of California.
rY
Date APPLICANT:
ALTER OR ADD TO MECH. 5.00 BUILDING /
} w NOTICI>TO APPLICANT: If,altar making this Certificate of Ex
Z emption,you shoWd became subject to the Workers Compensation APPLIANCE 5.00 aPLAN CHECK
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00 'FEE r
CONS"FRUCTION(.ENDING AGENCY AIR HANDLING UNIT(OVER 10MOC.F.M.) 6.00 SEISMIC FEE 19 r U
I hereby affirm that there is a construction lending agency kit EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permil is issued(Sec. MICROFILM
3097,Civ CA HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC
'1 I certify that I have read this application and state that the above
VENTILATION FAN (SINGLE) 4.00
information is currect, I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMM H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
abosC.irentioned property for inspection purpuses. BOILER-COMP Over t00,000BTU)SEE FEE SCH. MECHANICAL
f
/ (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. 1
Cupertino against liabilities,judgments, Costs and okpenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
gmntlD OL this perm it, MECH.CONT. LIC.NO. MECH.
TOTAL
fign r reD p ca / nine Er TOTAL �6
INSPECTOR COPY j