8288 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
T. BU LD1 NG PROJECT 1 DENTI FICATI ON PERMIT NUMBER
80'0 OI
® APPLICATION & PERMIT PLAN (^�{
t�2 BUILDING - ELECTRICAL-PLUMBING-MECHANICAL L!
- 828
OWNER'S yp$ 7 �LJ//� N CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE PLA
NAME T - OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S APPLIANCES
4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR 'g'7y�r { ApL,'IBTg$ PANELS (OVER 200 AMPI 20.00
NGINEER
LIC.NO. SIGNSTRANS. 3.00
ADDRESS ENO S pQOY06-� SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
WP EMP. METER OR POLE INS. 20.00
PucA s )30 like,
MOTORS SEE FEE SCH. •l �3-
ADDRESS ( s_ m Rd
SERVICE CHANGE 20.00
wo o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a u I hereby affirm that I ant licensed under provisions of Chapter 9 ISSUANCE DATE
ma (commencing with Section 7000)of Division 3 of the Business and
¢ BL ELECT. PLG. MECH.
F w i professions Code,and my license is in fill force and affect. ❑ ❑ ❑
2 o m - License Class Lic.Number
0 w r Date Contractor '
a Y s BUILDING PERMIT
¢ ¢o a U OWNBR-BUILDER DECLARA'NON INFORMATION
w3 u r 1 hereby affirm tlmt I am cxcmpt from the Contractor's'License MISC.- REFER TO ORD
u o j Law for the following mason.(Sec.7031.5,Besinessenl Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
� - Code:Any city crcouny whichregairesapermit to construct,alter,
¢ El
a,¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. Lm
u
O LL requires the applicant for such permit to file a signed statement that TOTAL ERMIT TO
F.
se w he is licensed pursuant to the provisions of the Contractor's License x
F z a
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe -
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r Oo the basis for the alleged exemption.Any violation o1'Seeton 7031.5 STIDRItS TWE CONSTR.
aim by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(S500).):
❑ I,as owner of the property,or my employees with wages asggCK FLOW PROTECT. DEV ICE 4.00 oec.GROUP E .uN IT
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,AR EA,COND. 5.00
Code:'file Contractor's License Law does not apply to an owner of '
' property who builds or improves thereon,and who do"such work FIXTURES-PER TRAP 5.00 So.FT. Loo AREA TOT41wAtREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-11INC.4 OUTLETS 6.00
or improvement is solJ within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
-,r builder will have the burden of proving that he did not build or int- UhlDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30:00 E IND CON PB Omer
��yy I,as owner of the property,am exclusively contracting with El 1:10
IicEhsed contractors to construct the project(Sea 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:I lie Contractor's License Law does not apply'
to an owner of properly' who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts 0msoch projects with a contractor(s)licensed pursuant to - SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT N0. PARCEL NO.
❑ I am exempt an Sec ,BAP.C.for it,,, WATER HEATER W/VENT 6.00
reason
Ow"e" WATER SYSTEM 5.00
I E ACC.FILE NO.-/
a
I K:RS'C yfwiN'n'ITON uGCLAR ION WATER TREATING EQUIP, 5.00
I hereby at tnor that I have a cert it icale Ot cnnsmrt to sell-insure. R; ZONING ENG.SITE NO.
in a crtifi,wi,of Workers;Compensation lnun
snxe,or a certified
copy thorcof(See 3800,Lab.CJ.
Policy No. Company
0 ❑ CertliedcopyisberebyfuDlistled' FIRESPRINK ENERGYT24
Z Z ❑ Certified copy Is tiled with the city inspection division. MISC.- REFER TO ORD.
p Appheam. y N❑ Y ❑ N❑
c m CERT'IFICA'TE OP I\EMPI ON PROM WORKERS' PERMIT ISSUANCE 10.00 FL D20NE A.L.U.C.
LU � COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG v O N❑ v❑ N❑
CL Z (]his sacfdn need not he completed if the permit is for one 1.TOTAL
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
U_ F- mit is issued,I shall not employ any person in any manner to as to
O e subject In the Workers'Compensation Laws of California.
O_ me nPplicanl BUILDING
} Do N CE 'I'O APPLICANT': If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00 h
F 2 Ex-
emption.you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the I-abor Code. you Most forthwith Comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER IQOOOC.FM.) 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,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name Q -•V err -4 '• - HEATING UNIT(OVER 100,000 B.T.U.)8.50
Lenlcr's Address ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
it]urination is correct. I ago ,to comply with all city and county
PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H:P.or 100,000 B.T.U.) 6.00
hereby aWhorizc ruff escntm fives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) aggro trr Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,ju igmm�ts, costs and e��pence��which CONST.TAX
may in any way a-crue again said it in r?cque Tela(the PERMIT ISSUANCE 10.00
g of r' t til u; MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
g ntra�r i
'` INSPECTOR COPY