8285 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
II BUILDING U • I APPLICATION & PERMIT ! �?�5
ADDRESS
_ If UIL G - ELECTRICAL-PLUMBING-MECHANICAL ,
�.
OWNERS PLAN CHECK VALIDATION
NAME '/l.� Tn w^�C�TC-� QTY. ELECTRIC PERMIT FEE
PHONE
AME OUTLETS-SWITCHES-RECEP 10.00/1.00
CONTRACTORS LIC.No. LIGHTING FIXTURES 10.00/1.00
ADDRESS REss APPLIANCES-RESIDENTIAL 4.00ko
PHONE PANELS 10.00 1i DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
on PANELS (OVER 200 AMP) 20.00
ENGINEER
SIGNS TRANS. 3.00
ARCH.OR ENG.I,l _ PERMIT VALIDATION
ADDRESS /lK^� S, $A2,1� �,-�s..n nyrs4 SPECIAL CIRCUIT 5.00
Ba ZIP EMP. METER OR POLE INS. 20.00
AmGFF.Ts A-V-Y MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 .
o o LICENSED CONT RACI'ORS DECLARATION TEMP.POLE 30.00 /9/st a o w 1 hereby affrtn that I am licensed under provisions of Chapter 9 ISSUANCE DATE
ya (commencing with Section 7000)of Division 3 of the Business and
Q n BLDO_ ' ELECT. PLG. MECH.
E z Professions Code,and my license is in Cull lOrce and effect
Z om - License Class Lie NumberEl
g Date-Contractor-
BUILDING
ateContractorBUILDING PERMIT
¢o a u .OWNFR-BUILDER DECLARATION INFORMATION
wg LL N I hereby affirn that I am exempt from the Contractor's License MISC.- REFER TO ORD
t• .. o Et Law for the followingreason.(See 7031,5.,Business and Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
Code'.Any city or county whidn requires a perm❑to construct,alter,
rtin Q improve,demolish,Or repair any structure,prior to its issuance,also ELEC.PONTA. LIC.NO. ELEC. a
o requires the applicant for such permit to file a signed statement that TOTAL I PERMITTO
w he is licensed pursuant to the Provisions of the Contractor's License Q
FZst I.aw(ChaPt,r9(COmmencfngwllh Section 70001ofDivision 3 of the /J / A
a Business and Pro1'cssions Code)or that he is exempt thcrchom and DTV. PLUMBING PERMIT FEE ,
¢ r o the basis for the alleged exemption.Any violation ofSection 7031.5 STORIES ' TYPE ONSTR
a '; � by any applicant Cora permit subjects the applicant to a civil penalty
o[n more than five hundred dollars(5500).): gLTER-DRAIN&VENT-WATER (EA.) 5.00
I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
Table compensation,will do the work,and the structure is not O C.GROUP RES.UNITS
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 Ur improves thereon,and who docs such work F IXTUR ES-PER TRAP _ 5.00 so.FT.EtoD AREA To ACREAGE
himself or through his own employe.,provided that such inrproes-
mentsarenotimendedcr offered fcrsa101f,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (Eq.) 2.00
builder will have the burden of proving that he did not buildror ire_ BUILDING USE
prr vc for purposeofsale-). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
I' • sed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code'The Contractor's License Low docs not apply
to an owner of property who builds Or improves thereon.and who LAWN SPR INKLERS-OVER 5 (EA.1 1.00
-eontraI for such projects with a contractor(s)licensed pursuant to
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACTNO, PARCEL NO.
❑ lam exempt under ,B-&RC.for this WATER HEATER W/VENT 6.00 ��
reason
Owner ^Date) WATER SYSTEM 5.00 cc.oat ACG FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 -
I hereby affirm flat I have a certifcme Of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No_ Company
O O Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z D Certified copy is riled with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y❑ N❑ Y ❑ N❑ .
m CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LL > I COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
EL O ('this section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑' N❑
Z hundred collars(S 100)or less.)
U O 1 certify that in the performance of the work lir which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued, I shall not employ any person in any manner so as to
b" subject to the Workers Compensation Laws of California. I^
a ate c Applicant BUILDING l"/
} to NOTYCIi TO APPLICANT: IL after making this Ccrt ificate of Ex- ALTER OR ADD-TO MECH. 5.00 _/
�, Z rption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
pruvvams of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10,CODC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby from that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) . 5.00
the performance of the work for which this per is issued(Secs MICROFILM
3097,Gv.C.). HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100, . . .
000 BTU)9.50 ELECTRIC
Lender's Addres �T�
I certify that I 741 this app tcotnon am stn c that the above VENTILATION FAN (SINGLE) 4.00 -
® inlonnu]ion is wrrccL 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMM H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP CO a,100,000 BTUI 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, crests and expenses which CONST.TAX
may in any way accrue against said Cit in a asequence of the PERMIT ISSUANCE 10.00
granting of cis perms MECH.CONT. LIC.NO. MECK r '
TOTAL TOTAL
ant/ ' tmc v' ate -
INSPECTOR COPY
t
1