8287 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING p44-All-PLICATION PLICATION & PERMIT 11
SUI '8287 A 7
s BUILDING -ELECTRICAL-PLUMBING-MECHANICAL `)4
i
NAM99-Ina 1
E B I _717UNCGrxTGI(t� PLAN CHECK VALIDATION
Gv P�T.vO QTY. ELECTRIC PERMIT FEE
® PHONE
NAMER CiO UTLETS-SWITCHES-RECEP 10.00/1.00
LIC NO. LIGHTING FIXTURES 10.00/1.00
ADDDRESORESS C
c Toas PPLIANCES-RESIDENTIAL 4.00
t PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
°R
ENGINEER
11- LIC.No. 1146n I SIGNS TRANS. 3.00
ARCH.OR ENGPERMIT VALIDATION
ADDRESS 5,SAeATtV A/5,wVA J#L SPECIALCIRCUIT 5.00
Zip EMP.METER OR POLE INS. 20.00
A I A-'a
/�O, e(a V MOTORS SEE FEE SCH.
ADOREu /T'Gr!
SERVICE CHANGE 20.00
tNSEDs.
o o ER CONTRACTORS'Ill RATION TEMP.POLE 30,00
a u v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE D TE
w G y( commencing with Section 7000)of Division 3 of the Business anA BLDG ELECT. PLG. MECH.
r w'n Profession%Code,and my license is in full force and effect ❑
i.0 m - License Class Lic.Number
O r° Date Contractor El ❑
a y.E.� BUILDING PERMIT
¢ ¢ OWNER-BUILDER DECLARATION
g ¢o n v INFORMATION
wg LL _ 1 hereby affirm that I am exempt from the C.Rtmetor's License MISC.- REFER TO ORD VALUATION
cc O ¢ Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10.00 SIFT.
two Code:Any city or county which requires apermit to constmeL.Iter. A
or Q Q 2 improve,demolish,or repair any structure,prior to Its Issuance,also ELEC.CONTR. LIC.NO. ELEC. (�-
K m 2 requires the applicant for such permit to file a signed statement that TOTAL PERMIT O
A w he is licensed pursuant to the provisions of the Contractor's License
HsiLaw(Chapter 9(commencing with Section 7000)of Division 3 of He
¢ Business and Poifiessmns Codc)or that he is exempt theretrorn and QTY. PLUMBING PERMIT FEE
¢ m the basis for the alleged eneio
mptn.Any violation of Section 7031.5 STO T. E STR.
T by any applicant fora permit subjects the applicxnlloacivllpunulty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars 05000LL
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OC OUP S. NIT
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,COND. 5.00
Code:The Contractoi s Lne ise law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP S.00 SQ FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
ments aro not intended or offered for sale.If.however.the building GAS-EA.SYSTEM-I1NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner. GAS-EASYSTEM-OVER 4 IEA) 200
builder will have the burden of proving that he did not build or im . . .
- BUILDING USE
Prove for purpose cfsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB CO.,
I,as owner of the property, in exclusively contracting with El El 13tic id contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL N0.
and Professions Code:'fhc 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 contractors)licensed pursuant to
the Contract.,',License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. •PARCEL NO.
❑ I am exempt coder See.-,B.&P.C.for this WATER HEATER W/VENT 6.00
eason
0won, Bete WATER SYSTEM 5.00 A aT ACC.FILE NO.
wRKERS'COM1 'ISN A ]ON DFCEAR ITON WATER TREATING EQUIP, 5.00
I hereby affirm that I have a certificate of consent to self-instar.. ZONING ENG.SITE N0.
Or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sce.3800,Lab.C.).
Policy No. Company
0 ❑ Certiliedcopyisherebyfuntished FIRESPRINK ENERGY T24
Z Z ❑ Certified copy is fled with the city inspection division. MISC.- REFER TO ORD.
0 Applicant v ❑ N❑ Y ❑ N❑
c w CERTIFICATE 017 EXEIJPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.UG.
LLQ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG
CL TOT.AL v❑ N❑ v ❑ NE)
(Phis suction need not be completed if the permit is for one
hundred dollars($100)or less.)
0 O_ 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL l- n.it is issued, 1 shall not cinploy an, person in any Rome,is,os to
0UIs nesubject to the Workers'Compensation Laws of California. BUILDING
u at2 Applicant ALTER OR ADD TO MECH. 5.00
} W N ICI:'ED APPLICANT: If,after making this Certificate of fix-
F Z hption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK"
provisions of the Labor Code, you must forthwith comply with FEE 3
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10,000QF.M.) 4.00
CONSTR UC'1'[ON LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
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
I 3097,CY.C.l. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name. l9'T/
Lcnder',AddueHEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 certify tot I have read thisappllcatlon and state that the above VENTILATION FAN (SINGLE) 4.00
Information is correct I agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned 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 expenses which CONST.TAX
may in any way accrue ngai t said City in consequ nce )the PERMIT ISSUANCE 10.00
gr;hntin of this IniL MECH.CONT. LIG NO. MECH.
TOTAL TOTAL
.trader
INSPECTOR COPY