C8684 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
WALMIG APPLICATION & PERMIT ��� n
Y nooaEss
l BUILDING- ELECTRICAL-PLUMBING-MECHANICA
OWNER' sm-xj- PLAN CHECK VALIDATION NAME �' QTY. ELECTRIC PERMIT FEE S 1/�1
• PHONE71
r NOME AcroRs UTLETS-SWITCHES-RECEP 10.0011.00
LIC.ND. i LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S
Rs
ADDRESS APPLIANCES-RESIDENTIAL 4.00
CO
A09dPHONEO)Z PANELS 10.00 DATE OF APPLICATION
A 1 C
OR PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEF7 P.C.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00
ADDRESS ENI. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zip TEMP.METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
o ¢ /
FOO LICENSED CONTRACTORS DECLARATIONTEMP.POLE 30.00
S - S
u I hereby a1Lnn that I am licensed under provisions of Chaptur'1 ISSUor u, UAN DATE
in a e- (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT.' PLG. MECH.
H w z Professions Co e,andA�ty license is in full fume ata e4e
Qi m o7 License Class ..�C�,Lic.Number .`4S 4fl"
Date J-tam- �S Cunlmctor
a m -J+ BUILDING PERMIT
¢ ¢ (E OWNER
-BUILDIiR UECLA RATION
A , a o INFORMATION
X 3 w y 1 hereby affirm that I am exempt from the Comrnctor's License MISC.- REFER TO ORD
to LL o J Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE ,w,s 10.00 VALUATION $/FT.
Coda.Any city or county which requires a permit In construct,alter, _
¢ ¢ Q 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. 3 S�
n %m or requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
zi
Law(Chapter 9(conuncriong with Section 7000)of Division 3 of the
E i o Business and Professions Code)or that he is exempt therefrom:rtd QTY. PLUMBING PERMIT FEE d :-✓
¢ I- m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TsPE CONSTR,
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAW& VENT-WATER (EA.) 5.00 Ts
of not more than five hundred dollars(5500).1:
❑ I,us owner.1 [[he property,or my employees with ev,s,as BACK FLOW 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 j' f
property who builds or improves thereon.and who does such work F IXTUR ESPERTRAP,,,, jS.OB SO.FT.FLOOR AREA TOTAL ACREAGE ,
himself a through to his own empld for S lcpIf,cd that.such improve `
o improvement is
or within on for o !,however,the building _r` GAS-EA.SYSTEM-1INC.40UTLETS"6.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving thus he did not build or int- BUILDING USE
prove for purpose of sale J. RES IND CON PB Other
❑ I,as owner of the property,em exclusively tixtumetingesith INDUSTRIAL WASTE INTER. 30.00 El ❑ ❑ ❑ E]
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 lir such projects with a contractor(s)licenscd,pursuant to
the Contractor's License Law. - ""'+. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT No. PARCEL No.
❑ I ant exempt under Sec,-,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 AOC.OATE ACC.FILE NO.
WORKERS'CO.MPEN'SATION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a certificate of consent to self-insure
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy theredf(See 3800,Lab.C.).
TPolico. Company _Mr _av
y N'O ❑ Certified copy is hereby f cot FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is file with the city inspection division.
21> ApplicantMISC.- REFER TO ORD.
Y [] N[] Y F] NE]
CC rn r PERMIT ISSUANCE 10.00
� - CIiR'I'IPICCONIPEEXEAIN INS FROM WORKERS' FLOOD ZONE A.LU.C.
W 0 COdI noN be c,INSURANCE the PLG.CONTR. LIC.No. PLG. Y� IN Y� IN
CL O This section Aced not be completed it the permit is for one TOTAL
� Z hundred Aollars 151001 or less.)
U O 1 cerllly that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner so as to
CD become subject to the Workers'Compensation Laws of Calif ornia. -
0.Ul [)are Applicant ALTER OR ADD TO MECH. 5.00 BUILDING b�
} m NOTICE '1'0 APPLICANT: If after making this Certificate of
Ex-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'
U such provisions or this permit shall bedeemcd revoked. AIR HANDLING UNIT(TO 1QO170C,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 construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the 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
Lender's Nddr HEATI NG UNIT(OV ER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC'
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
infonnation.,is correct. I agrtc to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.or100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property forinspection purposes. BOILER-COMP (Over 100.000 BTU).$EE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino gpiliti's,jud cots, costsandexpenses which CONST.TAX
may in an again said.City in consequence of Ice PERMIT ISSUANCE. 10.00
gmntingof tMECH.CONT. LIC.NO. MECH.
TOTAL TOTALSignat actor Date
INSPECTOR COPY