8260 (3) APPLICANT TO'FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT 1 DENTI FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS 0
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'$ PLAN CHECK VALIDATION
"nm Pa{�j�_9 ! I OTY. ELECTRIC PERMIT FEE
® DA E c o s 11eAF•/ `I UTLETS-SWITCHES-RECEP 10.00/1.00
.r LIc.No LIGHTING FIXTURES 10.00/1.00
., r, TRA 's (q n 13-1.15.1-' PPLIANCES-RESIDENTIAL 4.00
ADDRESS �V JO
�I-
OR PHONE PANELS 10.00 DATE OF APPLICATION
ARC RI c PANELS (OVER 200 AMP) .+'f 20.00 PLAN CHECK FEE
O
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION r�
rt:
SZIP EMP.METER OR POLE INS. 20.00
ADORE SS _ SEE FEE SCH.
A
MOTORS ///
SERVICE CHANGE 20.00 L1/
-�00 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 O/
¢u u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
2 a
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H Z Professions Cod- and r -'cense is in full fur'•a t ❑ ❑ rvr
Z O y- Crosse loss a1-e ,Lia Numbs 'I�u
.o'Z r•o Date Contracto '
i} N J
¢ y 2 BUILDING PERMIT
¢ 2w R SOWNER-BUILDER�ECLARATI01. ,,.�,.+^Y - - ----- INFORMATION
�,W 3 LL r- ' I hereby affirm (hat I am exempt from the Contractor's License - MISC:1- " REFER TO ORD 1 VALUATION $/FT.
"F n O J Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Airy city or counly which requires a permit to construct,alter,
IS improve,c o improve,demolish,or repair any structure,prior 10 its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- O E requires the applicant for such permit 10 file a signed statement that TOTAL ERM T O
a w m he is licensed pursuant to the provisions of the Contractor's License
H Z r
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe ,-rA
¢ Business and Professions Code)or Mat he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ F p the basis for the alleged exemption.Any violation of Sect on 7031.5 STORIES TYPE CONSTR.
a ; m by any applicant for a permit subjects u
Dro applicanou civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S5001.):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sale 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 df
property who builds o, immoves thereon,an llwho dors such work FIXTURESPER TRAP.- ni_ 5.00 SO.FT.FLOOR AREA TOTAL-ACREAGE
1 himself or through hus own employees.Provided that such improve-
ment,are not intended or offered for sale.II however,lire budding GAS-EA.SYSTEM-111NC.4OUTLETS 6.00
or improvement Is sold within one year of completion,(he owner- GAS-EA.SYSTEM-OVER 4 IEA.1' 2.00 BUILDING USE
builder will have the.burden of proving that he did not build or im-
provefor purpose ofsale.). - I
INDUSTRIAL WASTE INTER. r. 30RES IND CON Pa Omer
.00 I
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:"Phu Contmctoi s License Low does nal apply
to an owner of properly who builds or improves fiction.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts lint such projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.2001[/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ lam exemps under Sec. ,B,&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM - 5.00
ACC.DATE ACC.FILE N0.
WORK ERS'COM PENSATION DECLARATION WATER TREATING EQUIP. -A 5.00
_ I 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
I' -' th �38i00, b.0.)1 _Policy� RNpPl
� ertdid of Yr4Lrt5yfU FIRE'SPRtNK-. I
ENERGY T 2¢ 'Ir y
Z Z Cer If PY 's r r ty uc n.dlvi. on.
0 Applicant v MISC t REFER-TOrORD. t` 1 v❑-�rv'Q Y ❑ N❑ 'gig
t••"r' PERMI -ISSUANCE!-. T -110,00 � -
� - Cf: FICATI.OI LXESIP AOR FROM WO11KI R,, FLOODZONE, A. a
LU 1 COMPENSATION;INSURANCE PLG.CONTR. LIC:NO. PLG. -
` d O (This section nceJ nal be complete,] it the pennil is fur one TOTAL V❑ N❑ Y ❑ N❑
Z hrmdmd dollars IS 100)or less.I -
` ' U O I eertily that in (he perfimdance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
•LL I- mil is issued,I shall not employ any person in any manna,so as 10
0 U become subject to the Workers'Compensalion Laws of California. BUILDING
y Date Applicant ALTER OR ADD TO MECH. 5.00
} m
NOTICE TO APPLICANT': If,after making this CeH ifieald of E.
? com tion,you should become subject to(Int WorkersCompensation APPLIANCE 5.00 PLAN CHECK
Provisions of the Labor Code, You must forthwith Comply With FEE
` U such provisions or this permit slmll be deemed revoked. AIR HANDLING UNIT(TO 10)000C.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
tire
performanceCivaof the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name HEATING UNIT(OV ER 100,000 P..T.U.)9.50 t , ELECTRIC -�
Lender's Address
Icertify that l have read this application and stale that the above VENTILATION FAN (SINGLE) Y.: 4.00 1
information is correct.1 agree to comply with all city and county - PLUMBING +I
ordinances and state laws relating 10 building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,600 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for un,ection purposes. '
(We) agree to save, indemnify and keep harmless (he City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses whichCONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
gran' of this pe nn it. MECH.CONT. LIC.NO. MECH. low
TOTAL
Uq\\ \- n �a�(
�.�-m, TOTAL
S a pplrcan ontra<toz D Cn
INSPECTOR COPY