8227 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES = USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING / APPLICATION & PERMIT
ADORES,
V BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWN 'SI J�\ PLAN CHECK VALIDATION
NAME r.•� ) QTY. ELECTRIC PERMIT FEE
c -
o vA s
NAMEUTLETS-SWITCHES-RECEP 10.00/1.00
.
Jo. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP. METER OR POLE INS. 20.00
APPLICANTS1 /� f 1'�, MOTORS r SEE FEE SCH. n �
ADDRESS C ZU6�}U SJ�G Tt2I� �/V \V/J/�-
11II SERVICE CHANGE 20.00 /
o o CENSE;CONTRA&ORS DECLARATION TEMP.POLE 30.00 �}.�
a o v I hereby affirm that 1 a) licensed under provisions of Chapter 9 ISSUANCE DATE
y rt vai (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
D z I' rnf,,sions Code.and my license is in full form and rffcet.
z 0 e - License Class Lia Number
O m H ;ate Contractor
Y f BUILDING PERMIT
¢ ¢ ac a OWNER-BUILDER DECLARATION INFORMATION
O W> U MISC.- REFER TO ORD
w 3 N 1 hereby affirm that 1 am exempt from the Contractor's
License VALUATION $/FT.
Fa Nj Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00 ^ rf•sN-S
¢ ¢ 0 Code:Any city or county which requires a permit to construct.alter, �1yy.
Qimprove,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. l r•Jt` E
0¢ requires the applicant for such permit to file a signed statement that TOTAL / , -U
IL
EMIT TO
E
he is licensed pursuant to the provisions of the Contractor's License /
i
Law(Chapter 9(commencingwith Section 7000)of Division 3 of the ,
2 i o 1lusiness and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE /T�d, r•.,j
¢ $ the hdsis for the alleged exenhplion.Any violation of Section 7031.5 STORIES TYPE CONSTR.
au
by any applicant fora pennitsubjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500).):
❑ 1,as owner of the properly,or my employees with wags,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 Profusions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:'Me Contractor's License Law does mot apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE
himscl are otinthde owne)red fors. le,If,ed ever,the
improve GAS-EA.SYSTEM-11NC.4 OUTLETS 6.00
)rims are mens is
old or offered year o If,however,tote building
1 or improvement is so lA within one year ofcompletionhedit the owner-
bull •r wl1 have the buNah of proving that he did mol build or int- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 euaDlrvN USE
P for purpose of,:JeJ. INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omar
I,as owner of the property,am exclusively contracting with ❑ E ;0 El 11
I' en J contractors to construct the project(Sec. 7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
unit P fessions 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 forsu ewithacontraclortsl licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam rxempl under Src. .B.&P.C.foryttis WATER HEATER W/VENT 6.00
mason
X Uwnc Dw " WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
woRKISRs'Con1P1iNSATION DIKE ATI N WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a crrtifi,aI,of c event to xcll-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sce.3800,Lah.C.). - -
Pie icy No. Company
O ❑ Certified copy i,hereby furnished. FIRE SPRINK ENERGY T 24
Z 2 0 Certified copy is fled with the city inspection division.
0 Applicant MISC.- REFER TO ORD. YE] NE] Y ❑ NE]
y
CERTIFICATE 01'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
EL 0 ('('his section need not be completed it the pencil is for one TOTAL Y N Y NE]
hundred dollar,IS 100)or less.)
U 0 1 ce,tily 0hat in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is,is,ued, I shall not employ any person in any nmoner so as to
O w become subject to the Workeri Compensation Laws of California. BUILDING
D. Dale-Applicant ALTER OR ADD TO MECH. 5.00 -
} N NOT'ICF.TO APPLICANT: If,after making this Certificate of Ex- -
F 2 ennption,you should become subject to the Workers'Cunnpensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Calc, you must forthwith comply with
GJ such provisions or this permit Shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE a
. I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the peffonnamee of the work for which this permit is'issued(Sec. MICROFILM
3097,Civ.CJ, I HEATING UNIT(70100,000 B.T.U.) 8.00
Lender's Name r
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC • /
I certify that l hi,eread thisxpplictlion and State thxtmhe above VENTILATION FAN (SINGLE) 4.00
ity and cou
information is correct. I agree to comply with all cnty PLUMB( G
ordinances and state laws relating to building construction. and BOILER-IbIv1P(3 H.P.or 100,000 B.T.U.) 6.00 1
hereby authorize mprrsenratives of this city mo rmer upon the BOILER-COMP (Over 100,000 BTU(SEE 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 1000
CONST.TAX
may in any way accrue against said City in consequence of the -'-
'rnling of this penniL /7 MECH.CONT. LIG NO. MECH.
TOTAL '7 J) TOTAL .3020
Sig e phi and/C tPlate h /
INSPECTOR COPY
a I