8277 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING
G
APPLICATION & PERMIT ^ n
ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
iWilt \ XONE
CONTRACTOR's TLETS-SWITCHES-R ECEP 10,O6f(,00 ��
LIC. LIGHTING FIXTURES 10 1.00 -�-
A TOR PPLIANCES-RESIDENTIAL 4.00
ADDRESS
neONF ANELS 10.00 DATE OF APPLICATION
RC TECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER �_
LIC.No. SIGNS TRANS. 3.00 ,
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDREss
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
¢ o U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 70007 of Division 3 of the Business and BLD ELE PLG. MECFli
rZ Professions Cod• and my license v in full f ce an ( m.
z o m - License Class ' ^1 Lic.Number -
oz r Date Contractor
" - J
¢ x ¢ a OW Ii DER DECLARATION I ,ll iff
UI DING P RMIT
- o a " MISC.- REFER TO ORD INFORMATION
w ; LL H 1 hereby affirm that I am exempt from the Contractor's License VALUATION S/FT.
F u.o j Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE / 1
Code:Any city or county which requires a permit to construct,alter.
¢ Q p improve,demolish,or repair any structure,prior to its issuance,also EC.CONTR. LIC.NO. ELEC. /
CtI
3014u.
A m¢ requires the applicant for Such permit to fill'a Signed statement that TOTAL PERMIT TO
Abe is is licensed pursuant to the provisions of the Contractors License
F z i Law(Chapter 9(conimencing with Section 7000)of Division 3 of the
_ 4 a Ilusiness and Pmtessions Code)or that he is exempt thcretrnm and OTY. PLUMBING PERMIT FEE s
¢ e the basis fur the alleged exemption.Any violation of Section 7031.5 TOR TYPE CON TR.
a ;m ,by any applicant for it permit subjects the applicant Ina civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(SSOOL):
❑ I,as owner of the property,or my employeesrwith wages as BACK FLOW PROTECT.DEVICE 4.00 OCe. R 5. TS
their sole compensation,will do thr work,and the'�tmcture is not
1, intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Coder The Contractor's License Law does not apply to an owner of
DROP
erty who builds or improves thereon,and who does such work I F IXTURES-PER TRAP 5 SO,FT.FLOOR AREA TOTAL ACREAGE
ouglid• hams for thnintendsoofferdlot sale,11,
ed that however.the
improve GAS-EA.SYSTEM-IINC.4OUTLE/T8-
naNs urr not intended or n employees,
res,pr If however,the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 eulLolrvG USE
builder will have the burden of proving that he did not build or ire- R IND CON PB OaM1e.
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 IN El❑ 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sea 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 SSESSORS 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 a contraciof(s)licensed purAlmn to SEWER-SANITAR V-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ Iamexemptunder Sec. ,B.&IIC.Ibrthis WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
WORK ERS'COMPF.NSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby MENU that I have a certificate of consent to sell-insure,
or a certificate of Worked Compensation Insurance,or a eerlitied ZONING ENG.SITE NO.
copy thereol'(See 3900,Lab.C)'
Policy N "' (1JCompany
❑ Ce11If, PY is hereby furnished. FIRE SPRINK ENERGY T-24
z Z 60-Ce"ific copy is filed With the city inspection division. MISC.- REFER TO ORD.
p Applicant V NE] v ❑ N[]
~ it PERMIT ISSUANCE
IL - CGRTII'ICA T IiONSAII N INS FROMWORRCRS' FLOOD ZONE A.L.UL.
LU 1 CON INSURANCE G.CONTR. LIC.NO. PLG. V N V N�
CL Z (This section need not be completed it the permit is for one TOTAL a•-T
hundred dollars(S 100)or less)
U O 1 certify mut in the performance mf the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,1 shall not employ any Reason in any manner nN as to
become subject to the Workers'Compensation Laws ol'Calitoraia. /
�'DO Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING t`IY
} tr NOTICE 1'O APPLICANT: If,after making this Certificate of His-
♦- ? eruption,you should become subject to the Workers'Compensation 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
I hereby affirm that three is a constmetian lending agency for EXHAUST HOOD (WITH DUCT) 5.
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.0). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATI NG UN IT(OV E R 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct, I agree to comply with all city and county PLUMBING* /
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000B.T.U.) 6.00
hereby authorize representatives of this city es anter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
hereby
mentioned property forinsp ofth i Purposes,
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino a mast liabilities,judgments,costs and expenses which CONST.TAX
May in a way accrue against said City in consequence of the PERMIT ISSUANCE 10
ra Ingo II is Per»I. - MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Imre o Fn • t/ ontmct ate
INSPECTOR COPY
- I