7088 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
Rua DING APPLICATION & PERMIT
AD RE BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 7088
k� I
INNER PLAN CHECK VALIDATION
` AmE O Y. ELECTRIC PERMIT FEE
PHONE
co HAc R UTLETS-SWITCHES-RECEP 5.00/1.00
NA
LIc.No. LIGHTING FIXTURES 5.00/1.00
J CONTRACTOR'SRESS APPLIANCES-RESIDENTIAL 4.00
CONTRA
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS
6.00 PLAN CHECK FEE P.QNO.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR
ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ESS
ZIP EMP.METER OR POLE INS. 15.00
APPLICANT MOTORS SEE FEE SCH. S
ADDRESS
SERVICE CHANGE 10.00 /��/�S�-
0 o LICF.NSED CON'rRACfORS DIiCLARATION
a u D 1 hereby ufflrm that 1 am licensed under provisions of Chaple,9 ISSUANCE GATE
,w BLDG. ELECT. P
(commencing with Section 7000)of Division 3 of the Business and LG. MECH.
G i Professions Code,and my license is in full force and effect ❑ ❑ ❑ ❑
' 0. - License Class Lia Number
-
0 F w Date Contractor
BUILDING PERMIT
¢ ¢ wc OWNER-BUILDER DECLARATION INFORMATION
wo O MISC.- REFER TO ORD
3 A LL N 1 herchy affirm that I um exempt from the Contractor s License VALUATION $/FT.
HLLoJ Law for the followingreeson.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,alter,
-'-�-fl
at Q ¢ p improve.demolish.or repair any structure.prior to its issuance,at, ELEG CONTR. LIC.NO. ELEC.
¢ reyuins the applicant for such permit to file a signed statement that TOTAL PERMIT TO
d
as m¢ the is licensed pursuant to the provisions of the Contractor's License
H z rt Law(Chapter 9(commencing with Section 7000)of Division 3 oflhe
4 O Busincas and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE STVGaJ S/Vi/J(r'.
¢ r m the basis for the alleged exemption.Any violation of Sect ion 7031.5 STORIES TYPE CONSTR.
a3w- by any applicant fora permitsubjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.)4.00
of not mon than five hundred dollars(55000.):N
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the st'Re,me is not
intended or offered for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code', The Contractor's l.ittnse Law docs hot apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 S0.FT.FLOOR AREA TOTALACREAGE
• himself or through his own employees,provided that such improve-
ments are not intended or offered for sale If,however,the building GAS-EA.SYSTEM-11NC.4 OUTLETS 4.00
or improvement 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 provng that he did not build or im- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
T f; ❑ I,as owner of rhe property,am cxchhsively com,noing with ❑ ❑ ❑ ❑ ❑
licensed contractors lin construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:'I'he Contractor's License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts I'or such projects with a contractors)licensed pursuant to
the Cs traclor's License Caw.-_ SEWER-SANITARY-STORM EA.200ft/8-00 TRACT NO. PARCEL NO.
❑ Ian cxcm andr$m. - ,B.&P.C.for this WATER HEATER W/VENT 4.00
Owner Dare WATER SYSTEM 4.00 ACC.DATE ACC,FILE NO.
WORKER$'COMITNSATION DECLARATION WATER TREATING EQUIP. 4.00
I herchy affirm that l have a certificate ofconsenl Io self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
cup,thererf(See.3800,Lab.C.).
Policy No. ' Company
0 ❑ Cerlifned copy ishereby furnished FIRESPRINK ENERGY T-24
Z Z 0-Certified copy is fled with the city inspection division. MISC.- REFER TO ORD.
0 ApplicaN Y❑ N❑ Y ❑ No
fry CIiRTIFICAI'Ii017I7XIiMPI'IONFROMWORKI:RS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.C.
LU J COMI'IiNSATION INSURANCE PLG.CONTH. LIC.NO. PLG.
j CL 0 ('this s,tion need mol be completed if the permit is lis, one TOTAL Y❑ N❑ Y ❑ N❑
Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per, OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
O ED Dat., A licaor BUILDING SZJ
a PP ALTER OR ADD TO MECH. 4.00 7 11
} to NO'Il E '10 APPLICANT': II',after nuking this Certificate of Ex-
Z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10000QF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM,) 5.00 SEISMIC FEE d/ZJ
I hereby alfirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of Ilse work for which this permit is issued(Sec. MICROFILM
3097,CN.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name H EATI NG UN IT(OVER 100,000 B-T.U.)7-50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances cad state laws relating m building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby auflmrize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
uhovemhentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and exponses which CONST.TAX
may in any way accrue against vid City in consequence of the PERMIT ISSUANCE 3.00
g an InI'D,
of is per tt. MECH.CONT. UC.NO. MECH,
TOTAL TOTAL 2Ir'^ d`
Sig a ore o pplicam onrmctor Date /"
INSPECTOR COPY