C8280 9
APR 'ICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
• BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
APPLICATION & PERMIT / /
' BUILDING ( 8280
AOORE55 {
Y e �� j r BUILDING -ELECTRICAL-PLUMBING-MECHANICAL /
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
PRON
NONTRAcroFs C41h^ OUTLETS-SWITCHES-RECEP 10.00/1.00
/L 7 4. IC.No. ' LIGHTING FIXTURES 10.00/1.00
MNTRAICTORS I'ADDRESS µ /f- PPLIANCES-RESIDENTIAL 4.00
�lf A [' (¢e PRONE - PANELS 10.00 DATE OF APPLICATION
a CHITECTq PLAN CHECK FEE P.C.NO.
OR /!�/�� .j -�( 4 (� PANELS (OVER 200 AMP) 20.00
ENGINEER Y V
LIC,No. SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS SPECIALCIRCUIT 5.00
zIv rrEMP.METER OR POLE INS. 20.00 �C/j,
ADDRESS MOTORS SEE FEE SCH.
aoDREss
SERVICE CHANGE 20.00 /}/Ys
w o o LICENSED CON'T'RACTORS DECLARATION TEMP.POLE 30.00
a o o I hereby affirm that I am licensed udder provisions of Chapter 9 ISSUANCE DATE
-mz a, (commencin with Section 7000)of Division 3 of the Business and
¢ a g w' BLDG. ELECT. PLG. MECH.
F m z Professions Code,and license is full force md� c ,, ❑ ❑ ❑ ❑
z o m - License Class Liu.Number
O Fw� Da[e Codonvtor L_t_
¢ ieE BUILDING PERMIT
Be ¢O u ANI -BUILDER DECLARATION INFORMATION
I`is g LL r 1 hereby affirm that I am exempt from tire Contractor's License MISC.- REFER TO ORD VALUATION
co¢ Law for the following reason. 7031.5.Businessand Professions pERMIT ISSUANCE 10.00 S/FT.
-�� Code:Any city or countywhich requires a permit loconstruct.alleq
¢ rt a improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTH. LIC.NO. ELEC.
Be requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO nl
a.a w m w he is licensed pursuant to the provisions of the Contractor's License
Fi >
Law(Chapter 9(commencing with Section 7000)o-Division 3 ofthe S�
- a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT f FEE
¢ r o the basis for the alleged exemption.Any violation of Section 7031.5I _ 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 than five hundred dollars($500).):
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 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 F IXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
ments are not intended or offered for Sale If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 IEA) 200
builder will have the burden of proving that he did not hoild or int. - . - . . BUILDING USE
prove for purpose of sale.).- INDUSTRIAL WASTE INTER30.00 RES IND CON Pa Omer
❑ 1,as owner of the property,am exclusively contracting with . ❑ ❑ ❑ ❑ ❑
licensed contractors to construct tire project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs 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;I couractons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec,-,134P.C.for cols WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM '" 5.00 ACC.OATE ACC.FILE NO,
WORKERS•COMPIiNSAI[ON DECLARAT ION WATER'TREATING EQUIP. 5.00
I hereby affirm thin 1 have a certificate of consent to SCIGinsure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation hlsur:ul ce,ar u certifi'd
/ copy thereof(Sec.3800,Lab.C.). k
Policy No. Company
Q ❑ Ccrtil'I d c m s licuoy furnished. - FIRE SPRINK ENERGY T 24
Z Z r��,�{�Certified 'op rc tiled with the rty inspect io division. MISC. REFER TO ORD.
O� A{/pticanni ,1 Y❑ N❑ Y ❑ N❑
� N CERTIVFICA_TE OF EXEMPTIEXEMPTI ON 1,141WORKPERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU COMHTNSATION INSURANCE: PLG.CONTR. LIC.NO. PLG.
CL 0,, This section need not be complclud if the pennif is for one TOTAL Y❑ N❑ Y ❑ N❑
hu dred dullars(5100)or tusk.)
V•O 1\certity that in the performance of the work 1'or which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
Il U mit is issued,I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California. BUILDING �U ,
Q a Date Applicant ALTER OR ADD TO MECH. 5.00
} m NOTICE 'rO APPLICANT: If,after making this Certificate of lis- - ?
F 2 emption,you Should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
N provisions of the Labor Code, you Most forthwith comply with FEE 3
CJ such provisions or this permit sh.11 be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00 -S
CONSTRUCT'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE SC7
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 HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
1 certify that I have-read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
it is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating 10 building construction, and BOILER-DOW Q H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to Save, indemnify and keep ham I the City of misc.- REFER TO ORD.
Cupertino against li' ilitics,judgre IS, Cost;, n expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way true against m Cif Y nsequente Of he
granting:1,1 MECH.CONT. LIC.NO, MECH. O/
TOTAL TOTAL
u fA pI 1 ntm ale f/G /•
INSPECTOR COPY