8650 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
4BUI LD1 NG PROJECT I DENTI FIC ATI PERMIT NUMBER
MOLDING
oo 155 L v 7 3 APPLICATION & PER
Y BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 865{ 1
NAMO.NER'S PLAN CHECK VALIDATION
"AME I �/O(S 6Z�J_�/ZQY PTV. ELECTRIC PERMIT FEE
`kefb-NE 5.1
NAMER Rs \ UTLETS-SWITCHES-.RECEP 10.00/1.00
�, LIC.No. �Q LIGHTING FIXTURES 10.00/1.00
I ADDRESS pals APPLIANCES-RESIDENTIAL 4.00
+ P.A24-9aes PANELS 10.00 DATE OF APPLICATION
PC I
PTE PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
SIGNS TRANS. 3.00
ARCH.ORE G. PERMIT VALIDATION
�,. ADDRESS SPECIAL CIRCUIT 5.00
zlv TEMP.METER OR POLE INS. 20.00
APPLICANT'$
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 -f / �f F
0 o OF LICENSED CONT RACTORS UIiCLA kA'fION TEMP.POLE 30.00 i
U Lj 1 hereby affirm that 1 am licensed under provisions of Chapter 9
r 2 w ISSUANCE DATE
I ronunennng with Section 700e i of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r m i Professions Code,and my license is in full force unit effect O ❑ ❑
Lz o m - License Clan u Lia Numbcr r,-r
0 F 0 Uulc�_Contractor -
F J
w a O\ NER-BUILDER DECLARATION
BUILDING PERMIT
o A U INFORMATION
X ; u. F- I hereby affirm that I am exempt (rola the Contractor's License MISC.- REFER TO ORD il
ea v_ Law for the following reason. 703 I.S.Business and Professions PERMIT ISSUANCE VALUATION $/FT.
Code:Any city or county which rcquiresu permit to construct,alter,
0.00
L ¢¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. /0 7
a tr requires the applicant for such permit to file a signed statement that TOTAL g
a w he is licensed pufsuant to the provisions of the Contractor's License PERMIT TO
Fzi
Law(Chapter 9(commencing with Section 7000)of Division 3 oflhe
E i o Business unit Professions Code)or Ouht he is exempt therefrom and OTV. PLUMBING PERMIT FEE
Xo the basis for the alleged exemption.Any violation ofSection 7031.5 STORIES TYPE CONSTR.
r d32? by any applicant for a permit subjects the applicanuo a civil penalty ALTER-DRAIN (EA.)of not mom than five hundred dollars(S500),): s'w r/�
❑ I,as owner 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,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 does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
.. m
himself re through his own employees,Provided that such improve.
rr or improvemenotnt tended or withinoffered
onefor sale,year
If,mpletion the the owner.
GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement ill has is sold within one yam of completion, the owner- GAS-EA.SYSTEM-OVER 4(EA.) -' 2.00 J
builder will have the burden of proving that he did not build or im- BUILDING USE
prove 1,as owner
ofsale.). INDUSTRIAL WASTE INTER. . 30.00 RES IND 0 PB Omer
i. ❑ d as owner of the property,am exclusively contracting with ❑
licensed inions Cod toconstruct the project La do. Business LAWN SPRINKLERS-1 INCE V.B. 6.00 ASSESSORS PARCEL N0.
and Prolene of Code.The who
Contractor's License Law docs not apply
to contracts
owner of property who builds 1. improves rased uand who LAWN SPRINKLERS-OVER 5(EA.) 1.00 J/
the Cons nor such projects with a contrudorlsl licensed pursuant m x7 R CT -30
the Contractor's License law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
t ❑ [am exempt under Sec. ,B.&P.0 for this{}
. WATER HEATER W/VENT 6.00 azrm
� Owner - .- Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
M'OkKERS' OMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy Ihemof(See.3800,Lab.CJ.
Policy No. Cohn pa n TJ- ¢+
..U ❑ Certified copy is hereby furnished. !
Z Z ❑ Certified copy ¢ filed with the city inspection division. FIRE SPRINK ENERGY T24 h
O Applicam MISC.- REFER TO ORD. Y [] N❑ Y ❑ N[ 1
e CC rA CERTIFICATE OF Exi wrION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
1 I)
I LU 'a COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. NE Y� NE]
11 his section need not he completed if the permit is for one TOTAL v
Z hundred dollars IS 1001 or less.)
U O 1 certity that in the performance of the work for which this per- PTV. MECHANICAL PERMIT FEE FEE SUMMARY
L. U mit is issued,I shall not employ any person in any manner so as to
becomes bjeet to the K'orkers'Compensation Laws of California.
U y Date - \pphca"t_=�jy� ALTER OR ADD TO MECH. 5.00 BUILDING
to NO'f1Cii LICANT: IL a cr making t u ertl icatc of t. 7`
)- Z enhption,you mould become subject to the Workers Compens. APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with'^ FEE U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE '7
F 1 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 CJ, HEATING UNIT(TO 100,000 B.T.U.) s8.00
Lender's Name
Lender's Address HEATI NG UNIT(OVER4100,000 B.T.U.)9.50 ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) th.00
information is correct. I agree to comply with all city and county - PLUMBING
A ordinances and slate laws rending to building construction. and BOILER-COW(3 H.P.ori 00.000 B.T.U.) 6.00
hereby actioned representatives of city to enter upon the BOILER-COMP.low,100,000 BTU)SEE FEE SCH. MECHANICAL
hereby
hn entio rm property car inspection this
purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX J (fL
( nhay in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 ei� _
-� grantin cllts jL, MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
5ighnit I rat n uc r e
iINSPECTOR COPY