9206 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
A D / BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 9200
DWN,H, PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE �-�...
• aaal PHONE
NAMERACiR UTLETS-SWITCHES-RECEP 10.00/1.00 s '
uc.No.
LIGHTING FIXTURES 10.00/1.00
c-o r ACTDB's PPLIANCES-RESIDENTIAL 4.00
ADDRESS P.O•BOX (7 a �r„ Qp��ln
XdH0'd� lJ PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
on PANELS (OVER 200 AMP) 20.00
ENGINEER
uc.rio. SIGNS TRANS. 3.00
ARCH.OR ENG. / PERMIT VALIDATION
ADDRESS 1, i SPECIALCIRCUIT 5.00'
EMP.METER OR POLE INS. 20.00
APPLICANTS p //�� IMOTORS SEE FEE SCH. _
ADDRESS RQ'/JO , 6
&26
SERVICE CHANGE 20.00
00 •' LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
¢u I hereby al'lirn that I am licensed under provisions of Chapter 9 ISSUANCE
NCE DATE
z ec (esnn mm�cing with Section 7000)of Division 3 of the Business'and
a A. BLD ELECT. PLG. MECH.
F w Z Professions Code,and my license is in full force and effect El 11 ❑
z z m License Class C- 6 -Lie Number +�a f-I
9 w to Date!-18�:_Contractor-wie Fel o " _/q[L•
F m s BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
O 5 D INFORMATION
X 0 A. H I hereby affrat Illat I an exempt from the Contractor's License MISC.- REFER TO ORD
m VALUATION $/FT.
HLL0 J Law for the following reason.(Sec.7031.5.Busincssand Professions pERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
SE ¢ ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
u requires the applicant for Such permit to file a signed statement that TOTAL
PERM¢ w m he is licensed pursuant to the provisions of lire ConIT TOtractor's License T
H z r
Law(Chapter 9(commeacingwith Section 7000)of Division3 ofthn
a Business and Professions Code)or that be is exempt therefrom and QTY. PLUMBING PERMIT FEE In/7 Yir-)7w
¢ $ the basis for the alleged exemption.Any violation of Section 7031.5 1 TDR E TVPE COISBSTR.
ea
; � by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(S500).1:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.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,AREA,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 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
omnis are not intended proffered for sale.if howcee,,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS EASYSTEM .OVER 4(EA ), 2.00
builder will have the burden of proving that h - . - .
e did not build or im- BUILDING USE
6 prove for purpose of sale.). RES IND CON PB Other
❑ I,as owner or the properly,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ El rW ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSO ARCEL NO.
and Professions Code:I he Contractor's License Law does not apply
to in owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
lite Contractor's.License Law. TRACT NO. PARCEL NO.
❑ Ium exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT„- 6.00
Owner Date - WATER SYSTEM ` 5.00 ACC.DATE ACC.FILE No.
WORKS RS%COMPFNSATION D17CLARATION WATER TREATING EQUIP. 5.00 -
I hereby affirm thus I have a certifcateyfconsent to self-insure
or a certificate of Workers'Compensation Insurance,ora certified ZONING ENG.SITE NO.
Copy thereof(Sec.3800.Lab.C.).
I'o�i/CVS No. Company
O R)Certified Copy is hereby furuished� \ FIRE SPRINK ENERGY T-24
Z Z /❑a Certified ropy R filed with the city a pect I disision.
O plaall < MISC.- REFER TO ORD. 'v ❑ •N� v � NE]c.:,.,
CC to PERMIT ISSUANCE 10.00
LU - ;RTI PICATEOI'EAI 1PTINSURANCE PLG.CONTR. LIC.NO, PLG.
O (This section need not be completed if the permit is for one TOTAL Y N V N❑
Z 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
W I- mit is issued,I shall not employ any person in any manner so as to
U w become subject to the Workers'Compensation lawsof California.
y Date Applicant ALTER OR ADD,TO MECH. 5.00 BUILDING
} US NO'IICH TO APPLICANT: If,after making this Certificate of Ex- '
F-. ? enrption,-;on Should become subject to Ole Workeri Compensation APPLIANCE / 5.00 PLAN CHECK •�
pro
visions.of the Labor Code, you must forthwilh comply with FEE �.
U such provisions or this permit shall be decried revoked. AIR HANDLING UNIT(TO 10A CC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING 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
lite performance of the work for which this permit is issued(Sec. MICROFILM
3097,Cwv C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)Lenders Address ELECTRIC
I certify that l have read this applicalion and state that the above VENTILATION FAN (SINGLE) 4.00
infarnlation is correct. 1 agree to comply with all city and county - PLUMBING
ordinances and state laws relining I.-building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTUISEE 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, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
gr nli of tllis permit MECH.CONT. LIC.NO. MECH.
i TOTAL TOTAL
yy 'klatureof pp ant/Contras or Date 03 -
(03
�V INSPECTOR COPY