8155 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION "" PERMIT NUMBER
�,( BUILDING APPLICATION & PERMIT
/- ADDRESS /
BUILDING-ELECTRICAL-PLUMBING -MECHANICAL 55
zNER'S - PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
• 4.A !1 PHONE
C OR
� NAME e OUTLETS-SWITCHES-RECEP-10.00/1.00
NAME
LIC.NO. ( LIGHTING FIXTURES .10.00/1.00
f
IN nDURESS ions PPLIANCES-RESIDENTIAL 4.00
ovess , ,/
7j Ste: ,Q� e�PHOI0-',fS)-uy/ PANELS - 10.00 OAT E OF APPLICATION
ORRCHREC PANELS (OVER 200 AMP) 2000 ?S AN CHECK FEE P.C.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00
moo ESS OR ENG SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ASMOTORS SEE FEE SCH.
ADDREDDRESSS
SERVICE CHANGE 20.00
° ¢
02 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a U La I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
N , i (commencing with Section 7000)of Division 3 of the Business and
¢ BLDG. ELECT. PLG. MECN.
H y i Professions Code,and my license is in full force and effect ❑ ❑ ❑
Z 0 w- License Cla 61�E� Lic.Number
o z r CT Date Contractor
a m <� BUILDING PERMIT
¢ a OWNER-BUILDER DECLARATION
¢ w o INFORMATION
w ;a. 1- 1 hereby affirm that that I am exempt from the Contractor's License MISC.- REFER TO ORD
LL ILL j Law I'or the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
� - Code:Any city or coon ly which requires.pe..nit toconsVuct.alter,
Qrt¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
i wm¢ requires the applicant for such permit to file a signed statement lhet TOTAL PERMIT TO
oL he is licensed pursuant to the provisions of the Contractor's License
z¢
Law(Chapter 9(mmmencing with Section 7000)of Division 3 of the
i ° Business'and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE /
¢ I- m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR:
a ; _ .by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEV ICE 4.00 OCC.GROUP .RES.UNITS
sole compensation,will do the work,and the structure is not
intended on offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND., 5.00
Code:The Contractor's 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 TOTAL ACREAGE
himself or through his own employees,provided that such improve- 1.
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
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 in,- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON RB other
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,BusinessLAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:"I'lie Conhactor s License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts far such projects with.contractons)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 -ACC.DATE ACG FILE NO.
WORK E RS'COMPENS010N DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Li b.C.). -
Policy No. Company
❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
z Z Certified copy is EkA with the city inspection division.
O_ ? Apllcant��IOP4i , ::l121c, MISC.- REFER TO ORD. YE] N[:3 Y ❑ N❑
y CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
, L � CONIPENSA'IION INSURANCE PLG.CONTR. LIC.NO. PLG. y� N� V� NE]
Z 1' 1'his section need not be completed if the permit is for one TOTAL
hundred dollars(S 100)or Ic..)
U 0 1 certify that in the performance of the work for which this per- CITY, MECHANICAL PERMIT,. / FEE FEE SUMMARY
LL H mit is issued, Lshall not employ any Poison in any manner so as to
OL) become subject to the Worker.Compensation Laws of Cafifornio.
-r a Date Applicant �� ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE TO APPLICANT: If.after making this Certificate of fix
' H ? emption,you should become subject to the Workan'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with EE
C.1 such provisions or this permit shall M1c deemed revoked. AIR HANDLING UNIT(TO 10,000 C.F.M.)�j
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000 C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000B.T.U.0.50 ELECTRIC
I certify that 1 have read this application and stale that the above Ll VENTILATION FAN (SINGLE) 4
information is correct. ].agree to comply with all city and county PLUMBING
ordinances and slate laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.1 6.00
hereby authorize representatives of
this
thipurposes.s city t0 enter upon the
inspection above-mentioned properly for BOILER-COMP(Over 100.000 BTU)SEE FEE SCH. MECHANICAL n LY
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
` Cupertino against liabilities,judgments, costs expenses which CONST.TAX
may in way accru gain sty i onaquencc of the PERMIT ISSUANCE 10.00
MEDIA,CONT. LIC.NO. MECH.
To AL/ TOTAL
or o p cant on ract Date
INSPECTOR COPY -
I