8185 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
bIBUILDING PROJECT IDENTIFICATION PERMIT NUMBER BUILDING APPLICATION & PERMIT J ADDRESS
l� ILDING - ELECTRICAL-PLUMBING-MECHANICAL 8185
OWNS 'S I F 1. - - PLAN CHECK VALIDATION
1. NAME 1'- 11,
OTV. ELECTRIC PERMIT FEE
E
NAM. A R OUTLETS-SWITCHES-RECEP 10.00/1.00
VIA LIGHTING FIXTURES 10.00/1.00
1 AcrDR's
PDD ES APPLIANCES-RESIDENTIAL 4.00
r-
HON PANELS 10.00 DATE OF APPLICATION
ARCHi EC / PLAN CHECK FEE P,C.N0.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
� � SIGNS TRANS. 3.00 '
ADDRESS COSP ECIALCIRCUIT 5.00 ,•1 PERMIT VALIDATIONP EMP.METER OR POLE INS. 20.00
ADDRESS APPL1ET MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
°r 0 o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a z w .. I hereby affirm that I our licensed under prnvisions of Chapter 9 ISSUANCE DATE
¢ n (comeneing with Section 7000)of Division 3 of the Buoilsiness BLDG- ELECT. PLG. MECH.
tn
H m i Professions Cotte,'nd n y 'cense R in full fort d
z o w - License Cluss- r �J LiC.Number
Ss 2 H Date" Contract 1 -
Q ve J Ff
m ¢ OWNER-BUILDER DECL BUILDING PERMIT
-
.<
a v INFORMATION
X 3.. I hacity affirm that I am exempt from the Contractors Li nese MISC.- REFER TO ORD
- VALUATION $/FT.
� LLoa Law for the following reason.(Sec.7031.5.Busmessand Prof lions PERMIT ISSUANCE 10.00
,� ✓� Code:Any city orcounty whiehrNuiresapermttoconstr ,!.alter,
Z 4 o improve,demolish,or repair any structure,prior to its i mree,also' EIEC.CONTR, ❑C,NO ELEC,
iL m requires the applicant for such permit to file a signed atcment that TOTAL PERMIT TO
La he is licensed pursuant t0 the provisions of the Co rector's License
H z i Low(Chapter9(commencingwith Section7000 I'Divisior the
¢ o Business and Prol'cssiom Code)or that he is amps therefrom and QTY. PLUMBING PERMIT FEE
¢ r m the basis for the alleged exemption.Any vi tion of Section 7031.5 STORIES TYPE CONSTR.
,c _ by any applicant for a permit subjects th- pplicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars( 00).): -
❑ 1,as owner of the P.,city,o ny employees with wages as BACK FLOW PROTECT. DEVICE 4.00 Dcc.GROUP RES.UNITS
sole compensatio o th work,and the structure is not
intended or offered o s (Se 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CONE. 5.00 '
Code:The Contract L`e st aw does not apply to an owner of
property who builds impr or thereon,and who does such work FIXTURES-PER TRAP 5.00 sa FT.FLOOR AREA TOTAL ACREAGE
himsemeats are otinthhd wit mployersle I f,ed that however,
the
improve- GAS-EA.SYSTEM-l 6.00 /
mems are meet is
old o lin on for arse.If,mpleveq[he building F
or
improvement is sold renin one year.f completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE /
builder Will purpose
the Nen of proving firm he did not build or int RES IND CON PB Omer
prove fors owner ale.). INDUSTRIAL WASTE INTER. 30.00
❑ d as owner the property,he exclusively contracting with ❑
licensed contruc c to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 gssS550R5 PARCEL No.
and Profession ode:The Contractor's License s th docs not apply
to"downer (properly who builds or inflows thereon.and who LAWN SPRINKLERS-OVER S(EA.) 1.00
contracts f such projects with a contractor(s)licensed pursuant to 0
SEWER-SANITARY-STORM EA.20ft/10.00
Lite Cool etor's License Law. TRACT NO. PARCEL NO-
❑ I m exempt under SCC.-,B&IrC,for this WATER HEATER W/VENT 6.00
orOlo
0%I r Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 -
I hereby affirm that I have a certificate of consent to wiCinsun.,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec 3800,Lab.0 L
Policy Nlyf�(L4)�npuny �, �
O ❑ CerI dpy L#.hereby fturillfia, FIRE SPRINK ENERGY T20
z Z edified copy is fled with the city ins,eclion division.
p Ap !caul MISC.- REFER TO ORD. v �, N� v ❑ NQ
~ rn PERMIT ISSUANCE 10.00
Lu - CIiRTIPIGOM IFN-A ION ION FROM WORKERS' PLOOD20NE _..--A.L.u.0. !
W COMPENSATION INSU RANCF, PLG.CONTR. LIC.N0, PLG. V N V O N�
(This section need not be completed if the permit or one TOTAL
C10 hundred dollar,($100)
or less
f certify that in the performance of the work f which this per, FEE SUMMARY
LL F~ mil Is issued,I shall not employ any person n ny manner so as to OTY. !MECHANICAL PERMIT FEE
become sobject to the WorlSy�d Compensat Lawsof Cnlifornie.
� y Uate per( ALTER OR ADD TO MECH. 5.00. BUILDING
} rn NOTICE TO APPLI Tf It after eking this Certificate of six-
�. Z em ption,you should�Ome sub' lmlhe Workers'Compensation APPLIANCE 5.00 i� PLAN CHECK
movisions u( lire L b Co , you must forthwith comply with FEE
U such provisions of this Per ' shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONS' UCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,0WC.EM.) 6.00 SEISMIC FEE
I hereby off that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the ,Edon ce of lire work for which-this penni Lis issued(Sec. MICROFILM
3097,Ci J. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Londe . Name HEATING UNITdOVER 100,000 B.T.U.)9.50
3 ar's AJJr"ss - ELECTRIC
I certify that I have read this ep,licalim and State that the above VENTILATION FAN (SINGLE) 4.00
ordinances n correct. I agree to comply with all city and county BOILER.COMM H.P.or 100,000 B.T.U.) 6.00 Ov PLUMBING
ordinances and state lows relating to comply
with construction, and _
hereby authorize representatives tarries ec this city m enter upon the BOILER-COMP (OVar 100,000 BTU)SEE FEE SCH. MECHANICAL /7 r6�
hereby
above-mentioned property for vesp of this
puityrpo 1..
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. )vv
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE '7`."- CONST.TAX
may in any way accrue against said City in wnseq cote of the 100
grantingofthis en t IMECH.CONT. LIC.NO. I MECH. �0`!;7417 -
TOTAL TOTAL
Signa[urC an o c r e c
AA � SP TOR COPY
1