8276 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LOI NG PROJECT I DENTIN CATION PERMIT NUMBER
AAPPLICATION & PERMIT ����
ADDRESS
ooREss
BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
Ow E S ?o All PLAN CHECK VALIDATION
NAME gqlri: J2 OTY, ELECTRIC PERMIT FEE
Y PHONE
NBME CT OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR's
ADDRESS APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
• ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
Llc.rvo. SIGNS TRANS. 3.00
AARCH,OR
DDRESS END. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP FrEMP.METER OR POLE INS. 20.00
APPLICANT S
ADDRESS
���MOTORS SEE FEE SCH. /
SERVICE CHANGE 20.00
D to z TEMP.POLE 30.00
,00 LICENSED CONTRACTORS DL'CLARA'f10N
a u 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
v, a w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F m z Professions Code,and my license is in full force and effect. ❑ El 13z 0 w - License Class Lic.Number
O m t w Date Contractor
a m s BUILDING PERMIT
rc ela OWNER-BUILDER DECLARATION
A o a u INFORMATION
w3 H 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
f m O E Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00VALUATION $/FT.
Code:Any city orcounty which requiresa permit to construct,alter,
/////1
m a 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
n w0 an requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
m w he is licensed pursuant to the provisions of the Contractor's License
H z r
Law(Chapter 9(cummenciogwith Section 7000)of Division 3 ofthe
PY o Business and Professions Code)nr that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
M H m the basis lir,the alleged exemption.Any violation of Section 7031.5 STD ES TYPE CONSTR.
d _ by any applicant for a permit subjects the applicant ma civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500t)
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUPRES.UNITS
their sole compensation,will do the work,and the structure is nal
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:'rite Contract.,',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 70TALACREAGE
himselfor through his own employees,provided that such improve-
incusarenotintendedorofferedforsale.I L however,the building GAS-EA.SYSTEM-1 1 NC.4 OUTLETS 6.00
Of improvement is sold within one year of completion,the owner- GAS-EA SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build of ire- RES IND C N PB Ohbar
1 forp..rp..ee of sale). INDUSTRIAL WASTE INTER. 30.00 0 ❑ ❑ ❑
I,as owner of the property,am exclusively contracting with
tic d contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSO ARCEL NO.
an Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves tire.......and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such project illi a contruclons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors ns a TRACT NO. PARCEL NO.
❑ lam ex t a red r ye . .B.&Poco for this WATER HEATER W/VENT 6.00
reason
Owner19Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE N0.
WOR iRS'CO llf NSATION DECLARATION WATER TREATING EQUIP! 5.00
I hereby.]firm that I have o"Hificate of cm.4mht it,self-irnu r,
or a certificate of Workers'Compensation Insuranec,or a Certified ZONING ENG.SITE NO.
crony thereof(See.3800,Lub.C.).
Policy No. Company
0 ❑ Certified copy ix hereby furnished. FIRE SPRINK ENERGY T24
Z Z ❑ Certified copy is filed with fire city mspedion division.
0 Applicant MISC.- REFER TO ORD. v N YF] NE]
CCN CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U,C.
LU COMPENSATION'INSURANCE PLG,CONTR. LIC.NO. PLG. v N v NE]a. 0 (This section need not be completed if the permit is for one TOTAL
hundred dollars IS 100)or less.
0 O I certify that in the performance of the work for which this per DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any Himuerso as to
0L) icant become subject to the Workers Compensation Laws of California.
Q. Date ApplALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F ? c urnion,you should become subject to the Workers'Cmnpensut ion APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Coda, you must forthwith consply with FEE
CJ 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
1 hereby affirm that there is u construmi..n lending agency for EXHAUST HOOD (WITH DUCT) 5.00 �-V
tire 3097.performance of thMICROFILM
e work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that l have read this application and state that the above VENTI LATION FAN (SING LE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relatinglo building construction, and BOILER-COMP(3H.P.or100,000B.T.U.) 6.00
hereby au0mnze representatives of this city to cmc, upon the BOILER-COMP (Over 100,000 BTU)BEE FEE SCH- MECHANICAL
above-mentioned property for inspecb.n purposes.
(We)-agree to save, demnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino ag rest 11 ! rtie judgments, costs and expenses which CONST.TAX
may in t y will cr a minst said City in consequence of the PERMIT ISSUANCE 10.00
grm nit.h MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
nature jpUlaafflMontractor Date
INSPECTOR COPY