8595 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATION PERMIT NUMBER
BUILDINGA.08 ESS
APPLICATION & PERMIT A
ADDRESS l�
T , /_ q2. BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME
• QTY. ELECTRIC PERMIT FEE
(, :v vrnoNE
COON TERACTORS UTL ETS-SWITCHES-RECEP 10.00/1.00
Pd(,t_ o eLM7T
6tjuc.NO. -t.. LIGHTING FIXTURES 10.00/1.00 C'
ADDRESS rolls APPLIANCES-RESIDENTIAL 4.00
vHQr�cO� PANELS 10.00 DATE OF APPLICATION
IAPIOR Ec PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.O.NO.
R
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ADDRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTSMOTORS Z- SEE FEE SCH.
ADDRESS
v SERVICE CHANGE 20.00
o� = gV t�
r o O LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 Yjf�
v w 1 hereby uffinn thm I am li,to Ned under provisions of Chapter 9 r ISSU E ATE
v,a 'w (commencing with Section 7000)of Division 3 al tl¢Business and BLDG. ELECT. PLG. MECH.
H n z Professions Code,and my license is in full force and effect ❑ ❑ ❑
z O m - License Classes fit-Lic.Number311
r O Dale Contractor,
¢ w a� J VNEOWNEB-BUILDS [ Ali I N BUILDING PERMIT
- O A INFORMATION
K
I hereby affirm that I am ex Irom the Contractor's License MISC.- REFER TO ORD
LL O ¢ Law for the following reason.(See.7031.5.Businessand Professions VALUATION $/FT.
I- y N PERMIT ISSUANCE 0
> Code:Any crayon coo npair any regcluic permit nstiance,ltcq
2 ¢ 0 improve,demolish,or repair any stmCturc,prior to its issuan<c,also ELEC.GONTR. LIC. E -
D C requires the applicant for such permit In tile a signed statement that - ` TOTAL �J S PERMIT TO
A w m m he is licensed pursuant to the provisions of the Conter0or's License
FI >
Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and attQTY. PLUMBING PERMIT 'FEE
N m the basis for the alleged explion.An vi n oulioof Section 7071.5 STORIES TYPE CONSTR.
Ate _ by any applicant for a permit subjects the applicant to u civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more that five hundred dollars(5500)):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP REs.urvtrs
their sule coal penaation,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 alt owner of
property who builds Or ltllprov.there00,and vvbo does xueh walk FIXTURES-PER TRAP 5.00 SOFT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
meats are notintended or offered for sale If.however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving shot he did not build or im. BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 REs IND CON PB Other
❑ I,as owner a1'the property.am exclusively'contracting with ❑ ❑ ❑ ❑ ❑ -
licensed cantractors it, construe( the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License.Law Anes not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts far such projects with a contrtetolfs)licensed purse eat to
the Contractors License law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,Ii,SP.C.for this WATER HEATER W/VENT 6.00
Rican.
Owner Lie WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKS RS'COMPFNSA ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby atfrm that 1 have acertificate ofconsenl loself-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereaf(Sce.3800,LAC.).
�c. Policy No, Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY 24
Z Z Crli- copy is fled with the city .inspection division.
O Apncanet MISC- REFER TO ORD. Y❑ N❑ Y ❑ N❑
wL - I.ICATF OP EXIT M1f PT10N PROM WO 'ERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LL > COMPENSATION INSURANCE, PLG.CONTR. LIC.NO. PLG.
EL O 1'1'his section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
D Z hundred dollars(5100)or Iess.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any matmer so as to
O w become subject to the Workers'Compensitein Laws of California.
Date Applicant BUILDING
>_ DO NO'T'ICE TO APPLICANT: 11,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
F ? 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 be decnwd revoked. AIR HANDLING UNIT(TO 10=CF.M,) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,0DOCEM.) 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,CYC.), HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 -0
Lender's Address ELECTRIC J/ S
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information n correct. I agree to comply with all city and county BOILER-COMP13 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
henna, ac and stale lows relating m building construction, anA
hereby, authorize repmxa%Iatives of this city ht enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above mentioned property for inspection purpuscs.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
grail'% of this Peron MECH.CONT. LIC.NO. MECH.
h TOTAL TOTAL
gnat of Appicant/Conlracto Ua
INSPECTOR COPY