8381 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
- BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
wit-I.N. APPLICATION &'PERMIT
AOOREss I�(�
0 BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 14J,1714
OWNER'S I - PLAN CHECK VALIDATION
'NA"',E ,AL 1 1m� O QTY. ELECTRIC PERMIT FEE
® � ` ONE
NAMERAcroRs UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No, LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
OR
CHDEcr PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0.
ENGINEER
LIC.No, SIGNS TRANS. 3.00
ADDRESS END' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
a TEMP.POLE 30.00
F o 0 LICENSED CONI'RACTORS LECLARAT'ION /
'a u 0 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
Z w (conuncncing with Section 7000)of Division 3 of t_he Ihlsiness and
Q y BLD ELECT. PLG. MECH.
H w z Professions Codc,and my license is in full fora and effect.
z 0 m w License Class Lie Number Il
9.H Dmc Contractor
st x ec I I `BUILDING PERMIT
¢o n 0 OWNER-BUILDER DECLARATION INFORMATION
F
LL h 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
H LL o a 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.al ter, _
2 R Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
S, requires the applicant for such permit ID I'i lc a Signed statement that TOTAL r
K:
m he is licensed pursuant to(lm provisions of the Contractor's License PERMIT TO,
Hzse Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and QTV. PLUMBING PERMIT FEE
r 0 the basis for Ilse alleged exemption.Any violation of Section 7031.5 STORIES'® TYP CONSTR.
A. 3 by any applicant nor a permit subjects the applicant W acivil penalty
ofuol more than five hundred johns($500j) ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ I,as owner of the property,or illy employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
lint,sole compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner o1
property who builds or improves thereon,and who does such work - FIXTURES-PER TRAP 5.00 so.RT.FLOOR AREA TOTAL ACREAGE
hiriscmonis re through his own milpit for L.If,however,
d leve rude improve
mems are not intended oroffered ceselulL ho that suhubuddlpg GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, - . - . .00�ihe owner- GAS EASYSTEM OVER 4 (EA) 2
builder will have the burden of proving Out he did not build or im- BUILDING USE
prove for purpose ofsac.). I / '-� INDUSTRIAL WASTE INTER. 30.00 RES IND CON Pa Doer
O I,is.owner of the properly.am Cieloovely contracting will-i 0 ❑ ❑ ❑ /
licensed contractors to construct lire project(Sec. 7044,Business LA N 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.anA who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractions)licensed Pur}uam to / SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
the Con s for
sus License is w. +
❑ Iamexenlpluuder Sec. ,B.&PT:Tr.rthis WATER HEATER W/VENT 6.00
on \-
Owner H46 67iC4 Date so 5iibWATER SYSTEM 5.00 ACGDATE ACC.FILE NO.
WORK ERS'COMPENSAT10N DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a ce,tificmc of mnsem It,al Ginsurc, ZONING ENG.SITE NO.
or a cc,uficSIc of Workers'Compensation Insurance,or certified
copy thereof(Sec.3800,Lab.C.).-
Policy No. Company
0 ❑ Certified copy is hereby furnished.
FIRE SPR INK ENERGY T-24
HC) C)A Ilcunl Certified copy is tiled with the city inspection division. MISC.- - REFER TO ORD. y N v N
CC y CERTIFICATE OP EXEMPTION 17ROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.O.C.
W > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
i„ d O (This section need not be completed if the permit is for one TOTAL Y❑ N Y N❑•
=) Z hundred dollars($100)or less,)
U 0 1 certify that in the performance of the work for which this per- QTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued.I shall not employ any person in any manner so as to
0 w become subject to the Workers'Compensation Laws of California.
o. Date Applicant BUILDING �.
} to NONCH TO APPI.ICAN'r: IL after making this Certificate of lis- ALTER OR ADD TO MECH. 5.00
F2 cn0ttion,yon should become subject In the Worker,'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of Ilse Labor Code, you must lorlhwith comply with
U such provisions or this permit shall be decmcd revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00 FEE (.0.
C'ONSI`RUCI'ION 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.0-), H EATING UN IT(TO 100,000 B.T.U.) 8.00
Lender's Name H EATING UN IT(OVER 100,000 B.T.U.)9.50
Lenders Address ELECTRIC
Icertify lhmlhuveread this application and smteol"thevbove VENTILATION FAN (SINGLE) 4.00
• into rmalion is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building on an'
and BOILER-COMM H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city 10 en¢r upon lire
above-mentioned property for inspection purpoBOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
�.. us.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
_ Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00
may in any way acerite ag iusl Said Cily in consequence of the CONST.TAX
granting oft ¢pvOyLL� MECH.CONT. LIG NO. MECH.
"li,P////11 1p'� A S/�i BIr TOTAL TOTAL
Signatt e � ant el3r-- tc
INSPECTOR COPY
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