C8186 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTI FICATI N _ PERMIT NUMBER
BUILDING APPLICATION & PERMIT (/`/J'y/// ��
"DRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OwNER'S PICPLAN CHECK VALIDATION
NAME QTY.. ELECTRIC PERMIT FEE
PHONE _ eJ`•
HOME ACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
I LIC.No. ILIGHTING FIXTURES 10.00/1.00
ADDRESS roll's APPLIANCES-RESIDENTIAL 4.00 ,s
PHONE PANELS 1Q-00 rOY GATE OF APPLICATION
ARCHITECT
OR PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER "'
�-
LIQ.O. SIGNS TRANS. 3.00
ADDRESS ENG. PERMIT 5,1)0 PERMIT VALIDATION
,.•,,,...=h.,.e, .
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ZIP EMP.METER OR POLE INS. 20.00 '-
APPLICANT'S I,
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 {_
Doo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE D/
y
A a (commencing with Section 7000)of Division 3 of the Business and< BLDG. ELECT. PLG. MECH.
H m Z Professions Code,and vry license is in full force and effect- R
2 o m - License Class Lin.Number
2 m r � Uu[e Contractor
as m - BUILDING PERMIT
¢ a OW NIi R-BUILDER DBCLA RATION
3 o g D INFORMATION
w ; LL H 1 hereby all that I am exempt(¢um the Contractors License MISC.-- REFER TO ORD
.. o j Law for the following reason.(Sec.703 L5.Businessand Professions VAwATION $/FT.
H - g PERMIT ISSUANCE 10.OQ, ..._
,n Code:Any city or county which requires'v permino connruct,alfeq -
¢ W Q p improve,demolish,or repairuny structure,prior to Its issuance,also ELEC.CONTR. LIC.NO. ELEC.
D A. E ¢ requires the applicant for such permit to file a signed stwdmanl that TOTAL �I t/'f2
w m u he is licensed pursuant to the provisions of the Contractor's License �„ PEHMR TO
HZQ Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 D Business and Professions Code)Or that the is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ H $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
T ; _ by any applicant utr a permit subjects the applicant toa civil penalty
of not moredhan five hundred dollars(S500).): 62 ALTER-DRAIN&VENT-WATER (EA.) .5.00
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUPRES.UNITS
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: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 s0.FT.FLOOR AREA TOTALACREAGE
Q-• himself or through his own employees,provided that such improve-
6.00
ments are not intended or offered for sale.If,howeveq the building GAS-EA.SYSTEM-I INC.4 OUTLETS [f
or improvement is sold within one year of completion,tm owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). RES IND CON PB -Diner
❑ 1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑a ❑;
licensed coninwwrS 1. construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
! and Professions Cede:'rhe Contract.,',License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects with a cimtracl.no licensed pursuant to SEWER-SANITARY-STORM EA.200ftI10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ lam exempts oder Sec. ,B.&I'.C.For this WATER HEATER W/VENT 6.00
Asan
Owner Date 41 011L�01 WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKF:RS'CO PENsn'ITONDECLARATION WATER TREATING EQUIP, 5.00
I hereby aflirm Ilmt I h.,c.certificate of consent to set Gros..... ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(See.3800,Lab.C.). ` /
Policy No. Company.-/�/T ns� A
OCertified copy is hereby fernrshe . FIRE SPRINK ENERGY L24
Z Z CertifiuJ copy is Rledwith the city inspection division. MISC.- REFER TO ORD. O [:] Y [:]O Applimnt N N N
ir W CERTIFICATE OF EXEh1P1'ION PROM WORKERS' PERMIT ISSUANCE 10.90 e� FLOOD 20NE A.L.u.e.
LU > C'OhWENSATION INSURANCE PLG.CONTR. LIC.NO. PLG, C ❑ ❑ ❑ ❑
IThis seeiiou need not be completed if the pennit is for one TOTAL 30 Y N Y N
Cl- hundred dollars IS 100)or less)
U O 1 certify that in the performance of the work for which this pet- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
F rout it is issued.I shall not employ any pecan in any manner so as to
U become subject to the Workers'Compensation Laws of California. _vx
ED Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING a fJ
>_ W NOTICE'1'O APPLICANT: IL after making this Certificate of Ex-
F-,Z e,option,you should become sobjeet to the Workers'C.ngxnsatm, APPLIANCE 5.00 PLAN CHECK
ptnvisions of the Labor Code, You must fortlwith comply wilh FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT PTO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY Y AIRHANDLING UNIT(OVER 10=C.F.M.) 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 -y41(1 HEATI NG UN IT 100,000 B.T.U.)9.50
Lender's Name ELECTRIC T
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• intormation is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.or 100,000B.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. ,•qh
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD:
Cupertino against I''bilities,judg!tents, co s.and expenses which PERMIT ISSUANCE 10.00 CONST.TAX •h
may in any way ccme a ost ai Ci in consequen v of the
granting of this unit MECH.CONT. LIC.NO. MECH.
�. TOTAL TOTAL
p 00
Sign fAppfie /C a for a[e
INSPECTOR COPY