C8238 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTI IC TION PER ITNUMBER
BUILDING APPLICATION & PERMIT ���
CTRICAL-PLUMBING-MECHANICAL
OwNER'E PLAN CHECK VAL I DAT ION/
�x NAME _ CITY ELECTRIC PERMIT FEE
/ PHONE
NAMERAcroRs UTLETS-SWITCHES-RECEP 10.00/1.00
uc.No. Z 1 �' LIGHTING FIXTURES 10.00/1.00
f-ON ACTOR'
ADDRESS PPLIANCES-RESIDENTIAL 4.00
P ONE f -Z PANELS 10.00 DATE OF APPLICATION
/ ORcwrEcr PANELS 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEEH
LIC.No, SIGNS TRANS. 3.00
ADDRESS ENO. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 .` n,D 11
ADDRESSrS MOTORS SEE FEE SCH. cf+
D sz SERVICE CHANGE 20.00 11.1 9' �gg5
r o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 �U1`
a v 1 hereby affirm that I um licensed under provisions of Chapter 9
w a A. (commencing with Section 7000)of Division 3 of the Business and wesse E PLG. MECH.
F w z 1' fions Code,and my license is in full force and effect. ❑ ❑
- License Class Lia Number
''
m s- ° Date 4 1)�Contractorr
Qyf
'¢ ra w a OW'NF-R-BUILDER DECLARATION BUILDING PERMIT
a o D INFORMATION
X g n m I hereby affirm that I am exempt from tie Contractor's License MISC.- REFER TO ORD
O ¢ Law for the following reason.(Sec.7031.5,Business and Professions 10.0016VALUATION $/FT.
to - PERMIT ISSUANCEM
Code:Any City or county which requires a permit to construct,alter, IN
w ¢ 0 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO ELEC. (/(�[/
Ie requires life applicant for such permit to file a signed statement that TOTAL
w he i5 licensed pursuant to the provisions of the Contractor's License PERMIT TO
H z a
Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe -
4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ H$ the basis for the alleged exemption,Any violation of Section 7031.5 STORI 5 TYPE CONSTR.
aS ? by any applicant for a permit subjects the applicant to a civil penalty gLTER-DRAIN& VENT-WATER (EA.) 5.00
.. of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or...y employees will,wge
as as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the It
mCture is not OCC.GROUPRES.UNITS
intended or offered for sale(Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. b.00
Code:The Conlructor'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 O s0.Fr.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such in.Prove-
merits are not intended or offered for sale.If,however.the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or inlprnvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or Ga- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON ❑ Other❑
❑ d as nwncr of the property,he 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[',ministers Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
Contracts for such projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ lura exempt under Sec. ,B.&P.C.hrthls
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPFNSA1'ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affum for 1 have a certificate ofemasent to self-insure,
or a certificate of Wo •rs'Compensation Insurance,or a cenified ZONING ENG.SITE NO.
copy tmryl,f! 1. 11.
PoII No
z biA+QgYy/St-�--^�'-t�b-.
Ccr hfie copy is 1 ereb furnished. , FIRE SPRINK ENERGY T-24
Z Ccrtc copy f cT t m city inspeatlon t vlvon.
r0 itfuncantMISC.- REFER TO ORD. yEl N� Y0 "El
PERMIT ISSUANCE 10.00,.,�.CIiRTII'ICATIi PUNS'h1 P. I' OM1f WORKERS' FLOOD ZONE A.L.u.C. f
W C0.1f PfiNSATION INSURANCE: PLG,CONTR, LIC.NO. PLG.
CL 0 ('Phis section need not be completed if tie permit is for one TOTAL Y❑ N� Y [] N[
0 Z hundred dollars(S 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
UL F mit is issued,I shall not employ any Pers..in any I....mer so as m
O become subject to the Workers'Compensation Laws of California.
UJ
Italic Apvlicam BUILDING �y�•
} Us NOTICE TO APPLICANT: If,after making this Certificate of F-x- ALTER OR ADD TO MECH. 5.00 '
F _ nnption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with U FEE such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 6.00 SEISMIC FEE-
U
I hereby affirm that there is a c mUticti.n lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sea MICROFILM
h ti 3097,CIv.CI. HEATING UNIT(TO 100,000 B.T.U.) 8.00
(-enders Name a
Le...leis AddressH EATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC r^�'
I certify that l have r"d this application and state that theabove VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and County PLUMBING
ordinances and state laws slating to building construction, anti BOILER-COUP(3 H.P.or 100,000 B.T.U.) 6.00
hereby enthorixe representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned entioncd properly forinsp ofth i purposes.
(We) agree to save, indemnify and keep hu nn less the City of MISC.- REFER TO ORD. Q/
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 O
granting of this permit /MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Si re -.A'pplicent/Con raiaor Dale`
- ! INSPECTOR COPY