8532 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY rl
BUI,LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT Ul���
ADDRESS244� NG - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S // PLAN CHECK VALIDATION
NAME ` TY. ELECTRIC PERMIT FEE }1
PNONE L
CONTRACTORS I
NaMEUTLETS-SWITCHES-RECEP 10.00/1.00
uc.N LIGHTING FIXTURES 10.00/1.00 �•
CONTRACTOR'$
ADORER,DRESSAPPLIANCES-RESIDENTIAL 4.00.
A
_Y541 V
PHON PANELS 10.00 DATE OF APPLICATION
OPRCNrtECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
t
ENGINEER
' LIc.ND. SIGNS TRANS. 3.00
ARCH.OR ENG. r PERMIT VAL{�TION
ADDRESS SPECIAL CIRCUIT 5.00
I
1"I14�
ZIP EMP.METER OR POLE INS. 20.00 D
APPLICANT'S MOTORS SEE FEE SCH. UN 1985
ADDRESS
SERVICE CHANGE 20.00 J
k � p p
o o LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00 Yl�f Of CQ
"d
. 1 hi,ueb afllnn that I ton licensed under revisions of Chapter 9 Del lino
N Z 6 Y' P P ISSUANCE DATE
1 '(com ntenenlg with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
O '^ Professions Co m license is in full for f -t
O z=w License Class _Lic.Number 1:1 ❑ ❑
Date Contractor
a m E BUILDING PERMIT /
W ¢ a ER-BUILDER UECL. A' I
A °` Cm t s e INFORMATION
X g LL N I hereby aUu Ihul 1 am exempt fro ISC.- REFER TO ORD
.. o j Law for the following reason.(Sec.703 .5,I usinessund Profcsions PERMIT ISSUANCE 10.00 VALUATION $/FT.
- Code:Any city or county which requir a PC mil toconstruct,'lie,.
re ra Q Q improve,demolish,or repair any street e,p or to its is also ELEC.CONTE, LIC.NO. ELEC. I
O M requires the applicant for such permit to ire signed statement that TOTAL P gMIT TO/
K
m LL he is licensed pursuant to the provisions o' a Contractor's License I/
Hii Law(Chapter 9(commencing with Section 7000Lnf Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
L_
- o the basis far the alleged a xemption.Any violarnn of SccICL 7031.5 STORIES "T PEC NSTR.
nam byonyapplicanu'orapermitvubjecistheapplicuntmadvilpenalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred Aullms($500).1:
❑ I,as owner of the pwperl Y.or my employees with wages as BACK F LOW PROTECT. DEV ICE 4.00 OCCGROUPRES.UNITS
their sole Compensation,will do the work,and the,facture is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided[hut such iumrovo-
ments are not intended oroffeLed for sale if,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
.Y or,improvement is sold within one year of completion,theowner GAS-.EA..$V$TEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have tte burden of proving thatn
Ile did o , .
t build or in'. - EES+
prove for purpose of saleJ. INDUSTRIAL WASTE INTER. 30.00 IND CON' PB ' Other
❑ I,as owner o1 the property,am exclusively contracting with ❑ 0 F-1 ED
licensed 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 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 Contraetoos)licensed pursuant fI -
theConfudar'sLicenseLaw. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-.B.&P.0 for mi, WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACG FILE NO.
WORK I!RS'COMPIzXSATION DECLARATION WATER TREATING EQUIP., 5.00
I heraby atfirm that 1 have u curtificute of consent k,self-insure. ZONING
or a certificate of workers'Compensation Insurance,or a certified ENG.SITE N0,
lhcpc
pc) tf l5ccp3 0Q_7bYfulod r�Inrs /,/e
0 64I'jt�l oll� a d 11'00 4 FIRE SPgINK ENERGY T24
Z_ Z ,`�(Crrlil fed copy,is fled with the CiLy inspe ision. MISC.- REFER TO ORD. y 11 IN El r'E:] N[]
O NVpnc
~ w+ PERMIT ISSUANCE 10.00
cc CAnted
'AT.OF I!XEMPTION FROM ORKERS' DZONE A.L.U.C.
LU > COMP17NSA'I ION INSURANC. PLG.CONTR. LIC.NO. PLG, y N v N
� 0 (This not be completed if the permit is for one TOTAL
hundred dollars IS100).or less I
U O 1 certify that in the performance of the work for which this per, OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any manner so as to
U become Raided to the Workers'Compensation Laws of California.
LU Dare Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE '1'0 APPLICANT: If,u teremaking Ibis Certificate of Ex.
F 2
caption,you should become subject to the Workers'Compensalion APPLIANCE 5.00 PLAN CHECK
provisions of (lie Labor Corlc, you most forthwith comply with FEE
U such Provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=11F.NL) 4.00
CONSTRUCTION LENDING AGENCY 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 perfomwnce of the work for which this pemlit is issued(Sce. MICROFILM
3097,Civ.C.), HEATING UNIT(TO 100,000 B.T.U.) 8.00
Leader's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information is Correct. 1 agree to comply with all city and county BOILER-COMP(3 H.P.Dr 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives forfinsec this city es enter upon the ,BOILER-COMP lover 100.000 BTU)SEE FEE SCH. MECHANICAL
herebyln autioriz property forinsp of
purposes.
(We) agree to save, indemnify and keep Il arnlcss the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which j PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
granting of thispermit MECH.CONT. LIC,NO. MECH. ����
TOTAL TOTAL
41
b'1 d m C 1 L a tOf ate
INSPECTOR COPY