8212 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS r� A / 1
Zo6OS G, V Z O(ZGO I✓r- BUILDING -ELECTRICAL-PLUMBING -MECHANICAL ' jV� G I G
OWNER'S - PLAN CHECK VALIDATION
NAME V r'
C M/ QTY. ELECTRIC PERMIT FEE
1 C PHONE
CONTRACTOR S
UTLETS-SWITCHES-RECEP -10.00/1.00
LIC.NO.Z�7�ZJ LIGHTING FIXTURES 10.00/1.00
r -
CONTRACTOR
OR's
ADDRESS PPLIANCES-RESIDENTIAL 4.00
-,Wb Sdr O (fY.Al O' oNE '7NI-7272 PANELS 10.00 DATE OF APPLICATION
OARCHITECTPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
' 5'4-N.< uc.No. SIGNS TRANS. 3.00
ARCHE OR ENG. - SPECIALGIRCUIT 5.00 PERMIT VALIDATION
pH'CC ZIP TEMP.METER OR POLE INS. 20.00 A ^
ASMOTORS' SEE FEE SCH. /(! /t�--�ud�✓
ADDRESS
f0. G '
SERVICE CHANGE 20.00 - PAID
0 0 0 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a o i. I hereby affirm that I am licensed under provisions of Chapter 9. I♦I SSUANe DATE
z w (commencing with Section 7000)of Division 3 of the Business and
w ¢ y LOG. L Ctj PLG. MECH.
r w z Professions Code,ppnd myy license is in full force'a4Rmd� f=feel ❑ ❑ ❑
Z O m- License Class L -/G Lia Number ''L /f Z
o m ra
O Dale Contractor
a "J BUIEDINt PERMIT
¢ ¢ ¢ OWNER-BUILDER DECLARATION
A o a O INFORMATION
w 3.LL H I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
u o a Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Iwv4 Code:Any city or county which requiresapermit to construct,alter, p'6 ,26
Ic in ¢ O improve,demolish,or repair any structure,prior t0 its issuance,also ELEC.CONTR. LIC.NO. ELEC. D D
a O o requires the applicant fur such permit to file a signed statement that - TOTAL PERMIT TO
w m he is licensed pursuant to the provisions Of the Contractor's License
Law(Chapter 9(commencing with Section 7000)ol-Division 3 ofthe p
- ¢ Business and Professions Code)or that he isexempt therefrom and QTY. PLUMBING PERMIT FEE Ql�K
¢ F o the basis for the alleged exemption.Any violation of Scetion 7031.5 STORIES TYPE CONSTR,
o ;W by any applicantfor,a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00 of not more than five hundred dollars(5500).):
❑ I,as owner of lire property,or my employees with wages 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,GOND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SQ.FT.FLOOR AREA TOTAL ACREAGE
himsemeats are notthrugh intends own emred forssle.If,ed that howevr,such improve- GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
mems arc me intended or offered for Sala It, mpleveq the building
be 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 that he did not huild or ire- - BUILDING USE
.prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND 1:1 PB Omer
❑ d as owner of the properly,am e exclusively. 7044,contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project La does Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Property
The Contractor's License Law does not apply
Io tr owner of properly who builds tr improvesIh ensed pu nua who - LAWN SPRINKLERS-OVER 5(EA.) 1.00
1 contracts for such License
projects with a conlructod sl licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 '
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,B&ILC.for this WATER HEATER VV/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
wORKI:RS'COMPENSA'rION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent to Self-insure. ZONING ENG.SITE NO.
ccertificate of Workers'Compensation Insurance,or a certified
opy therijjiA((Sec 8g8099,Lal,CJ. f
Policy NoIYAld MSSimpany 5t,�
O ❑ CerlifiedcopYls hereby furnishc r FIRE SPRINK ENERGY T-04
Z Z 9 Certified o}LY�it fined with the mly inspection division. MISC.- REFER TO ORD.
O Applicant Y ❑ N❑ Y ❑ No
F- y PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
Lu CIiRTIFICATEOE6 OT ION FROM WORKERS'
W � COMPIiNSA'I'ION INSURANCE PLG.CONTR. LIC,NO. PLG.
CL O (This section need not be completed if lire pennil is for ane TOTAL Y❑ N❑ Y❑ N❑
Z:) Z Imo died dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued.1 shall not employ any person in any manner so as to
U become subject to the Workers'Compensation laws of California. O
U.1 Dale Applicant ALTER OR ADD TO MECH. 5.00 BUILDING 5-
} N NOTICE TO APPLICANT: If,after making this Certificate of Fx-
F Z emptlon,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK p 7
provisions of the Labor Code, you must forthwith comply with - FEE �_ .�J
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.N ) 4.00 ;
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10)000CEM.) 6.00 ; SEISMIC FEE 0. 63
1 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,Clv.C.), HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 0.00
ordinances n correct. I agree to comply with all city and county PLUMBING
ordinances and stale laws relating oc to building construction, andmy 130ILEA-COMPI3 H.P.Or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000BTU)SEE FEESCH. MECHANICAL
x above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. v
Cupertino against liabilities,judgments, .,is and expenses which CONST.TAX
may in any way accrue ag rest aid C'y in consequence of the PERMIT ISSUANCE 10.00
ter gUf 115 perm p[' MECH.CONT. LIC.NO. MECH.
3-Zo y TOTAL TOTAL Z 3 S G
Signature of Applicant/Contractor Date
OFFICE COPY - ---�