6812 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
ADHDING APPLICATION & PERMIT ���
nUILDIN
SS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OW Ens PLAN CHECK VALIDATION
NAME VUfC-c / ffj/(- QTY. ELECTRIC PERMIT FEE
AlAqAPHONE
CO.TRncrO s
NAE Cia - UTLETS-SWITCHES-RECEP 5.00/1.00
M
LIC.No. L LIGHTING FIXTURES 5.00/1.00
corvrnncrons /�//1p PPLIANCES-RESIDENTIAL 4.00
i ADURE55 C/f/O
nnUrvE PANELS 5.08 DATE OF APPLICATION
AR ETEC SIGNS 6.00 PLAN CHECK FEE
On
ENGINEEn
.No. SIGNS TRANS. 3.00
ARCW OR Nc. r SPECIAL CIRCUIT 5-� PERMIT VALIDATION
AoonEss '07 83QLGM/ONS iEZD
Z.Pfte
EMP.METER OR POLE INS. 15.00 -•f/"`'�
ADDRESS MOTORS ' SEE FEE SCH.
nroness
t00 SERVICE CHANGE 10.00
o o LICENSED CONfRACLORS DECLARATION /
a u v I hereby affim+that I am licBmed under provisions of Chapter') ISSUANCE GATE
w Q (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
R N z Professions Codi and^�y license is in full farce d,g f t.
z o - I-keno Class r",L�Lia Number
❑ ❑ ❑ ❑
o = w Date6yb Cant aimr
a Y s BUILDING PERMIT.
¢ w ¢
OWNER-BUILDER UGCLARA"f ION INFORMATION
doAD MISC- REFER TO ORD
w 3 LL r I herfby affirm(hal I am exempt from the Contractor's License VALUATION S/FT.
u.o a law for the following reason.(Sec 7031.5,Business and Professions PERMIT ISSUANCE 6.00
� - Code:Any city(it county which requiresa permit toconstruct.alter, r
F¢ rt Q improve,demolish,or repair any structure,prior to its issuance,also ELEG CONTH. LIC.NO. �� ELEC.
O reyuims the applicant for such permit to file a signed statement Ihal t` _ TOTAL PERMIT TO
d w se u he is licensed pursuant to the provisions of the Conl actors License F..+ vw..iiv
Uzi Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
- ¢ Business and,professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
IS r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
e- f2 by any applicant for a permit subjects the applicant loacivil penalty - ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars($5000.):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP HES.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. 4.00
Code:The Contractor's License law dens not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 s0.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
mentsare not intendedoroffered Hit sale.It,however,the building GAS-EA:SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden Affirming that he did not build or int- RES IND CON APB OMer
prove for purpose of sale.). INDUSTRIALWASTE INTER. 20.00 El ❑ El :E1 El
I,as owner of the property.am exclusively contracting with
licensed contractors to iNionoc, the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or impulses thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with «mm
a tracr(sl licensed pursm uato
thetmets a o License Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sue. ,BAP,C.]or Hits WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.OATE ACC.FILE NO.
WORKERS'COMPENSA IION DECLARATION WATER TREATING EQUIP. 4.00
I hereby atOrm that I have a certificate of consent IN sal Ginsure, ZONING ENG.SITE NO.
...
a cert iGcate of Workers'Comp u :'tion Insurance,or ertifial
copy I - •af t set.agoo,Lab.c.). j.Q:dY S r"
1'0' No. Company-/N1[1A
0 Cerificd copy is hereby furnished. " FIRE SPRINK ENERGY T24
2 Z Certified copy is filed with ihu city inspection division.
Q p'iant MISC.- REFER TO ORD. Y ❑ NE] Y ❑ IN
NCERI'IFICMEOF EXIiMPTION FROSI WORKERS. PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C,
Lu 5; COMITNSATION INSURANCE PLO.CONTR. LIC.NO. PLG.
CL O (This section need not be completed if the permit is for one TOTAL Y❑ NY ❑ NEI
Z) Z hundred dollars 1S 100)or less)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- If it is issued,I shall not employ any person in any manner sn as to
U hccome subject to the Workers'Con,pcnsation Laws of Califomin.
n. Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} en NOTICE 70 APPIACAN'I': IL after making this Certificate of E.
cmption,you should becmne subject to the Wurkrri Cnmperx.tion APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
V "tell,provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10SWC.F.M.) 3.00
CONS'T'RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10000C.EM.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction Icnding agency for EXHAUST HOOD (WITH DUCT) 2.00
0m pc,fonnance of the Work for which this permit is issued(Sic. MICROFILM
3097,Civ.C.). r, HEATING UNIT(TO 100,000 B.T.U.) 4,00
Lender's Name ee4o HEATING UNIT(OVER 100,000 B.T.U.)7.50
LCndcr's Address ELECTRIC �; O
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
• information is correct. I agree to comply With BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 all city and county PLUMBING
oolounces and state laws relating to building construction, and
hereby authoriec representatives o1' this city to enter upon the BOILER-COMP(Over 100,000BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree It, Hive, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against Iiubditics,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in co,cyucnce of the PERMIT ISSUANCE 3.00
granting of this permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
=nalpni,ttulApplican bounctor to
' INSPECTOR COPY