9276 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT 8276
ADDRESS
UILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWN - PLAN CHECK VALIDATION
NAM OTY. ELECTRIC PERMIT FEE
PHONE
c Nr Ac aR UTLETS-SWITCHES-RECEP 10.00/1.00
N ME
O., LIGHTING FIXTURES 10.00/1.00
AO R PPLIANCES-RESIDENTIAL 4.00
DNess
RODE ( PANELS 10.00 DATE OF APPLICATION
ARCRITE T PLAN CHECK FEE P.C.NO.
on PANELS (OVER 200 AMP) 20.00
ENGINEER
�c.NO, SIGNS TRANS. 3.00
ARCH,
HADDHE OR ENG.
SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 PAID
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS JUL 121985
/ SERVICE CHANGE 20.00
0 0 o LICEN 'D CONTRACTORS DECLAR 10 TEMP.POLE 30.00 MANY
p.�
o U 1 hereby coffins that I am licensed under provisions of Chapte CII AN YQvUP
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT PLG. MECH.
DZ Professions Code,and my license is in full force and effect,
z o m- License Class Lia Number ❑ ❑ ❑
O Uale Contractor
-
< r E .�, BUI G PERMIT
¢ w 4 OWNER-BUILDER DECLARATION INFO NATION
od0 MISC.- REFER TO ORD
as 3 u y I hereby affirm that 1 am exempt from the Contractor's License, VALUATION $/FT.
a, LL o 4 Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
as Code:Any city or county which requires a permit to construct.alter,
2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC:
- ort requires the applicant for such permit to file a signed statement that TOTAL ,!
u w m m he is liwnsed pursuant to the provisions of the Cmdo'clor's License PERMIT TO
Hz >
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 Business and Professions Code)or that he Is exempt therefrom and QTY. PLUMBING PERMIT FEE
r the basis for the alleged exemption.Any violation of Section 7031.5 STORIES WE'CONSTR,
o ; � by any applicant for a permit subjects the applicant o acivil penaltyALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).):
O 1,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 Contractors License Law does not apply to an owner of
properly who builds or improves thereon,and who docs such work F IXTURES-PER TRAP 5.00 SG.FT.FLOOR AREA TOTALACREAGE
• himself re through tinto his own employees,provided that such i a, in-
hients mself a not intended or emplo ee sale.Tided that such
he building GAS-EA.SYSTEM-1 INCA OUTLETS 6.00
or improvement Is sold within one year of completion,the 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
Pro'e r purpose of sale.). INDUSTRIAL WASTE INTER. 30,00 RFS IND CDN PS Omer
.as owner of the properry.am exclusively contracting with ❑ ❑ ❑ ❑ ❑
lice d emo, Ion to construct the project(Sec 7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
in
r fessions Code:The Contractor's License Law docs not apply
to n owner of property who hnilds or improve thcnon,Inul who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
c ntract,fnrwell projectSwith a comractons)becuseJ pursuant io SEWERSANITARV-STORM EA.200ft/10.00
tl a Contractor s Liccoat Law. TRACT NO, PARCEL NO.
rrlo,I,P�'R
exemunder See ,B.&I.C.fix tisWATER HEATER W/VENT 6.00
1;1 ,Z Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
S'COMPENSATION 'CLARATIONWATER TREATING EQUIP. 5.00
that I have a certificate of consent Lo self-insure, ZONING ENG.SITE N0.
"'me f Workers'Compensation Insurance-or a terrified
copy thereof(See.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished, FIRE SPRINK ENERGY T24
z;Z ❑ Certified copy is filed with the city inspection division.
MISC.- REFER TO ORD.
'O Applicant V❑ N❑ Y ❑ N
= W. CIi R"TI FICA"Ili OF li X17M VI'ION PROM WOR KERS' PERMIT ISSUANCE 10.00 FLOODZONE A.LU.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL
Z (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y C] N❑
hundred dollen IS 100)or Tess.)
U O I certify that in theperformance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued.I shall not employ any person in any manner so as to
become subject to the Workers'C'omperuaton Laws of California. -
a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} WNOTICE '1'0 APPLICANT: If,after making this Certifieme of Ex-
F_ 2 emption,you should become subject m the Workers Commensation APPLIANCE 5.00 PLAN CHECK
Provisions of the Labor Code, you must forthwith comply wit FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p0DC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the 3097 performance of the work for which this permit is issued(See HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.5G Lender's Address ELECTRIC
I certify that l hove read this application and state Out the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
.o irem"s and state laws relating to building construction, and BOILER-COMP I3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP 00ver'100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree ro 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
n' in eny way accrue against sxid iry in ronsequcncc of the
ran ng of Ibis permit MECH.CONT. LIC.NO. MECH.01.9 /*
TOTAL TOTAL
5�('X'pJTrjcaNt1CortracT5r I Date'
INSPECTOR COPY