8392 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LOI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING - APPLICATION & PERMIT
ADDRESS /1
BUILDING-ELECTRICAL-PLUMBING -MECHANICAL Lxr\
/ OWNER'S PLAN CHECK VALIDATION'
NAME OTY. ELECTRIC PERMIT FEE � /� �-'r
CONTRACTORS
R �/ / ��` PHONE / S�/.lA///�/0
NAME LTOR'S U
NAME �,,_OUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
DDRESCTORs
A 5 - - - PPLIANCES-RESIDENTIAL 4.00
I DpRE5
GPHorvE C" L(I PANELS 10.00
( 41 -�/ / ) DATE OF APPLICATION
ARC CTPLAN CHECK FEE P.C.NO.
on PANELS (OVER 200 AMP) 20.00
SIGNS TRANS. 3.00
ARCH Ess ENG' SPECIAL CIRC 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 ,1
ADDRESS MOTORS SEE FEE SCH.
1 1 SERVICE CHANGE 20.00 Vt
i--
w02 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a u I herehy affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
n G m (commencing with Section]000)of Disi0 3 of the Business and BLpG. ELECT. PLC. MECH.
H m Professions Code,and my license is in full( ce 3na effect- ❑ ❑
Z o w - \ LiIte CP.x Lic.Num
o N F o 1 1)a[e Contra, q
a , E , BUILDING PERMIT
¢ ¢ w OWNER-Bm LD1: C , T N INFORMATION
X LL r 1 hereby affirm that 1 am u,empt from the Conti dot's Lic se MISC.- REFER TO ORD
VALUATION SIFT. y l+
u o¢ Law for the following reason.(Sec.7031.5,Hit
Professions 10.00
- �, PERMIT ISSUANCE /�d-o
Code:Any city or county which sequitur a punmit to const alter
R ¢ ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. /� �y
¢ requires Ilse applicant for such permit to file a signed statement that TOTAL PERMIT TO
w he is licensed pursuant to the provisions of the Contractor's License
Hzi Law(Chapter9(co nrococo,with Section 7000)of Division 3 of Dm
4 er Business and Professions Code)or that he is exempt therefrom and CMO LQ
¢ 1 pthe basis for the alleged exemption.Any violation of Section 703 LOTV. PLUMBING PERMIT FEE 5 STORIES
n N TYPE CONSTR.; to by any applicant for a permit subjects the applicant(oacivilpenalty ALTER-DRAIN&VENT-WATER (EA.) 5.00 S
Of not more than five hundred dollars($500).):
❑ 1,as owner of tire property,or fly employees with wages as BACK F LOW PROTECT. DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the sT ruemre 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 an owner of
property who builds or improves thereon,and who does such work . FIXTURES-PER TRAP 5.00 S .FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,prnvided.that such.improve-
mentsarenotintendedoroffered for sale.If,however,the building - I- PAS,_EA.SYSTEM-1%INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner-
builder will,have the burden of proving than Ile did not build or inn- GAS-EA.SYSTEM=OVER 4(EA.) '2,00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 3000 RE 5 IND CON PB Omar
❑ 1,as owner of the properly,am exclusively contracting with . ❑ ❑ ❑ El " ❑
licensed contractors to construct the project(Sec.7144.Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Cade: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
centrads for such projects with a contract,),(,)licensed pursuant to
the Contractor's License Law. Y SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
reason❑ l am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM , 5.00 ACC.GATE ACC.FILE NO.
WORK FRS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofconsent to self-insure.
or a certificate of Workers'Compensal ion Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lah.C.).
Policy No. Company
O ❑ Certified copy ishereby furnished. FIRE SPRINK ENERGY T 24
Z Z,. ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
V N V N
-~-y-- "' PERMIT ISSUANCE 10.00
�'- CIiR'fIFICA'I'li OF EXEMPTION WORKERS' FLOOD ZONE A.L.U.C.
LU :> COMPENSAT ION INSURANCE PLG.CONTE,�_ LIC.NO. PLG. ❑ ❑ ❑ ❑
= Z his section need not be completed if the perni( is for one TOTA
(TL V N Y N
Q hundred dollua($100)or less.)
I certify that in the performance oDthc work for which(),is per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued I shall no(employ any/B�son m (manner so as Io
DO become eu lfct t iheN'orker{ti�lC,�y�'ipFnsu(iot 3ws of California.
0.w [)atc�C�/Applicanl�( ALTER OR ADD TO MECH. 5.00 BUILDING 1�
� m NOTI {- I PPLIC,IN'f u !maklrt'•tt rY rt Fate of Lx-
Z_ e..... ,yoL should bete<subject to the Worker'Cumpensa(ion APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthWith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE co
I hereby affirm that (here is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of tire work for which this permit is issued(Sec. MICROFILM
3097,Civ C.), HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lenders Nume
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC /(p
1 certify that I have«ad this application and slate the(the above VENTILATION FAN (SINGLE) 4.00 `
ordinances is state. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and slate laws re ling to building construction, and
hereby actioned representatives of on city m enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. ,MECHANICAL
abovehereby
intioned property for inspection this
purposes.
(We) agree to save, indenmify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses Inch PERMIT ISSUANCE 10.00 CONST.TAX
n
may in apy way accrue against said Ity in co equece o the
s -
ranlin O(ihi5 i//miL / / MECH.CONT, LIC.NO, MECH.
Y t� ei...44 //� i. _ 7 TOTAL
/ /f TOTAL S-0
3 Sti alum of Apphca tContractoi �/ Dutc - �l
INSPECTOR COPY
I `/