9256 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
OUILOINc APPLICATION & PERMIT
ADDRESS
(•� v . A a ILDING-ELECTRICAL-PLUMBING-MECHANICAL9256
OWNER'S J PLAN CHECK VALIDATION
NAME
QTY. ELECTRIC PERMIT FEE
S/LV�Y(flJu oiF,cc �,I€�Tc�
CONTRACTOR'S / y UTLETS-SWITCHES-RECEP 10.00/1.00
/f {� /•' (. uc.NO. f / LIGHTING FIXTURES 10.00/1.00
.ONrRAMI - APPLIANCES-RESIDENTIAL 4.00
ADORE55
G -��/PI(ONE PANELS 10.00 DATE OF APPLICATION
pq mTEc PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.N0.
ENGINEER -
uc.NO. .. SIGNS TRANS. 3.00
AARCH 0.DDRESS ENG, SPECIAL CIRCUIT 5.0Q PERMIT VALIDATION
ZIP FFEMF.METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
¢ u I hereby affirm Lha, 1 am licensed under provisions m`Chaptar 9 ISSUANCE DATE
mG w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F w z Professions Code and m license is in full fur a and ffect. ... ❑ ❑ ❑
z 0 w - License Class Lic Number
Z,t w Date Contractor
a m BUILDING PERMIT
¢ ¢ ¢ WNER-BUILDER DECLARATION
C
a o MISC.- REFER TO ORD INFORMATION
K
g u w I hereby ulfinn Lhal I am exempt from ,hc Ccu tmctor'v License
apta Law l'ar the following mason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT-
f � > - Code:Any city or county which requiresa permit to construct,alter,
¢ u, a improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
u reunions tire applicant for such permit to file a signed statement that TOTAL PERMIT TO
w he is licensed pursuant to the provisions of the Contractor's License
F z i
Low(Chapter 9(commmming with Section 7000)of Division 3 of t he �� U'/ 'S
a Business and professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ = $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
u ; _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S50OT):
❑ I,as owner of the property,or my employees with wagesas .BACK F LOW PROTECT.DEVICE 4.00 OCC.GROUP ROES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale(Sea 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5XO Gh
Code:The Contmaor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP SAO UL so.RT.FLOOR AREA TOTAL ACREAGE
•
himselforthrough his ownemployees,for sale.
If,ho ever,hat chimprove GAS-EA.SYSTENI INC.40UTLETS 6.00
mems are not intended or offered Cor sale-If,however,the building
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- Bt1IL0ING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 3000 RES IND CON PB Other
LII,as owner of the property,am exclusively contracting with . ❑ ❑ ❑ O
licensed contractors to construct the project(Sec. 7044,Businss LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:'Flat,Contractor's License Law Rocs nut apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts fur such projects with a contrachnds)licensed pursuant In 1RM EA
T
RY
ANIT
SEWER-SA -SO .200ft/
the Contractors License Law. � TRACT NO. PARCEL NO.
❑ lam exenhpt under Sec. ,H.S.P.C.fur this WATER HEATER W/VENT 6.00 Ou
reason
Owner Date WATER SYSTEM 5.00 A,Oa ACC.DATE ACC,FILE NO.
+_ \ WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby alfirm that I have a certificate of consent to self-insure, ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(See.3800,Lab.C).
Policy No. Company
❑ Cctlilicd C" creby furnished. FIRE SPRINK ENERGY T24
z ❑ Certified cwv/ filed wit the pee' division.
Ox Applicant- ll%%JJg x ( �- I MI C.- REFER TO ORD. Y N� Y N�
~ �+ �� PERMIT ISSUANCE CC T LES I'IFICA 11;ONSATIOTIION ROMWORKERS' PLG.0 PER. UC.No. PL 1-QQ 0_0 FLOOD ZONE A.L.U,C.
CL O (Phis section need not be completed if the Permit is Ibr one TOTAL � Y N[ Y ❑ NEI
:D Z hundred dollen,,$100)or less.)
U O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
1.L I- mit is issued.I Shull not employ any person in nny mann¢sn as to
0 Ubecome subject to the Wom
rkens'Copnnsution Lawsof California.
W Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NONCE TO APPLICANT': IL utter making this Certificate of Ex-
H ? cnhption,you should become subject to the Worker,'Compensation APPLIANCE 5.00 PLAN CHECK
provision' of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000GF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the perl'onnance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lenders Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this apphriamo and slate nkat the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING ,0.0
ordinances and state laws relating to building Construction, and BOILER-COMPI3 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 BTU)SEE FEE SCH. MECHANICAL
above mentioned property for inspection purposes.
(We) agree to save, indemnify and keep hurndess the City of MISC.- REFER TO ORD.
t Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any, wry accrue against said City in eonscq Renee of the
I'D, g bis permit. MECH.CONT. LIC.NO. MECH.
\, mract , 7/,o/•?,r,
TOTAL TOTAL
J� SI c 1 App /UmH aoleor'`�5-i e�t�-
INSPECTOR COPY