C8252 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ONQ_ PERMITNNUMBER
N
BUILDING APPLICATION & PERMIT I\l//✓//
ADDRESSA2 3A3 Abig- 4
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OwrvER'a PLAN CHECK VALIDATION
252
�-�/OTV ELECTRIC PERMIT FEE
vRorvE
NAt"4ERAcrofls UTLETS-SWITCHES-RECEP 10.00/1.00
i� R UC,NO, LIGHTING FIXTURES 10.00/1.00
ADDRESS rofl'sr��� PPLIANCES-RESIDENTIAL 4.00
rrlt�s77�� /`M ' PANELS 10.00 DATE OF APPLICATION
pq Hlrec PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
I.C.No, SIGNS TRANS. 3.00
ADDRESS ENG. PERMIT 5,00 PERMIT VALIpATION
ZIP TEMP.METER OR POLE INS. 20.00 _
APPUCANT'S MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
y t I
wGO LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 s �S
BE
U U7 1 hereby affirm that I em licensed under provisions of Chapter 9 ISSUANCE DATE
H < y� (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H i Professions Cod,.' my license is in lull fort• L ❑ ❑ ❑
0 O w - License Class Lic.Number
4 Z I- w IJalc Contractor
- r4
u BUILDING PERMIT
a a w
NE -B UILUER DIRax�irl
INFORMATION
W ;LL,N I hereby affirm that I am cxempontractor's License MISC.- REFER TO ORD
D< Law for the following reason.(Sec. ProfessionsVALUATION S/FT.
PERMIT ISSUANCE 10.00 �^
Cope:Anye,d mulish county repur which reqstructes a ure, rmltloconsuance,also ELEC.CONTR. LIF NO. -1
BE
, xt 0 improve,demolish,or repair any structure,prior to its issuance,also FILEd
D u requires the applicant fur such permit to file a signed stame enl that ' TOTAL PERMIT O
u w he is licensed pursuant to the provisions of life Contractor's License _
FiQLaw(Chapter 9(commencing with Section 7000)of Division 3 oflhe
z D Business and Professions Code-)or(hal he is exempt therefrom andOTV. PLUMBING PERMIT FEE �� l
a H $ the hasis fur life alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more Oran five hundred dollars(8500).):
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE '4.00 - OCCGROUPRES.UNITS
their sole compensation,will do the work,and the sl Eamon,is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00 -
Code:The Contractor's License Law docs not appl,to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SD.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such implove-
menlsavenotintenold or within
onefor
year o 11,mpletion the building GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement rs sold within proving
year that lie
(fie it owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving(hal lie did not build or inn BUILDING USE
prove for purpose of sale.). RES IND CON PB Out,
❑ 1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑
licensed contractors to construct the project(Sic- 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions 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 contentions)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor',License Law. TRACT NO. PARCEL NO.
❑ Iain exempt under Sec...B.&P.C.for this WATER HEATER W/VENT 6.00
rea5011
Owner Date WATER SYSTEM � ,(L + ACC.,OATE ACG FILE NO.
WORK F-RS'COM PENSA,rION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to sel Ginsure.
or a certificate of Workers'Compensation Intern cc,or n certified ZONING ENG.SITE NO.
copy Ihee, f ec.3 00 Lab.C.l. /�..-. •r
Policy No puny
Certiliedc a ,Eby for ed FIRESPRINK ENERGY,T 24
z Z Certified op is fled with tl ins ¢lion div' n. ❑ E] ❑ ❑
O IAP MISC.- REFER TO ORD. v N v N
rn CP TIF C IOTSf'IC p6RKISIYS' PERMIT ISSUANCE � 110. 0
FLOOD ZONE A.L.U.C.
W ( 11'IiN'SAT ie INSURAN Ch 1 PLQ CONTR. LIC.NO. PLG.
CL Z CL 0 (T Is s,cDon n d not he tompI ISit if life permit is fur one TOTAL Y N� Y No
hundred dollars(5100)or Icss)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- not is issued,I shall not employ any person in any manner so as to
Ow become object to thie WorkerCompensation Laws of California.
C. DateApPlic"ret J ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE 'f0 APPLICANT': If,atter making this Certificate of Ex-
emption,you should become subject to the Workers'Contesal ion APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U' such provisions or this permit shall be deemed revoked. r AIR HANDLING UNIT(TO 10000C.F.M.) 4.00
r
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10000C.F.M.) 6.00 SEISMIC FEE
I hemby al'finn thus there is a consvuclion lending agency for EXHAUST HOOD(WITH DUCT) 5.00
life performance of Iht 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 +
Lender's Address / HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
aroellma ccs n estate(. I agree to comply with all city and county BOILER-COMP(3 H.P.cr 100,000 B.T.U.) 6.00 PLUMBING
ordinesus and slate lows relating to building wnslrud inn, and
hereby aullmrize representatives of this city toen ler upon the BOILER-COMP (Over f00,00o BTU)SEE FEESCH. 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,ju Rents, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
accme ugai t said Cly in com equene of the1.,*
ermit' MECH.CONT. LIC.NO. MECH.
TOTALTOTAL /Slicant/CdWictor I
/Jjs, INSPECTOR COPY