6782 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION - PERMIT NUMBER
BDILDING - APPLICATION & PERMIT
ADDRESS
BUILDING-ELECTRICAL-PLUMBING ECHANICAL 6782
WNEI�b PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
• CONTRAICTOR s OUTLETS-SWITCHES-RECEP 5.00/1.00
NAME
LIC.NO. LIGHTING FIXTURES 5.00/1.00
N A -
A TORS
ADD APPLIANCES-RESIDENTIAL 4.00
CO
p at ONE PANELS 5.00 DATE OF APPLICATION
A C E SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
nooAess ENc. SPECIAL CIRCUIT5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
APPLICANTS ',n„ /fie Lw MOTORS SEE FEE SCH. \ V I
ADDRESS VYM IJLLNC.�
SERVICE CHANGE 10.00 �dS�
woo LICENSED CONTRACTORS DECLARATION /
u u 1 hereby affirm Thal I am licensed under provisions of Chapter 9 ISSUANCE DATE
h3 n (commenting with Section 7000)of Division 3 of the Business Ed BLDG. ELECT. PLG. MECH.
H w i Professions Co 1 I license is in full for"•a1 f et
z o w - License('lass&1 Lic.Number ❑ ❑ ❑
z r w Dalcl .lLi..lContmclor
a IS 11 LL{{YY/ BUILDING PERMIT
IS w � OWNGR-B UILDIiR DECLARATION
A o A MISC.- REFER TO ORD INFORMATION
w 3 u y I hereby uHinn that 1 am exempt from the Conlraclor's License VALUATION $/FT.
.. oQ Lawforthefollowingreason.(Sec.7031.5,Bminessond Professions PERMIT ISSUANCE 6.00
~ I4 Code:Any city orcounty which requires a peril to construct,alter,
2 R Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
o ¢ ruquires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a w m he is licensed pursoint to the provisions of the Contractor's License
FZI Law(Chabot,9(commencing with Section 7000)of Division 3 oflbe
4 Business and Professions ode)or that he is exempt Om ref'rom and QTY. PLUMBING PERMIT FEE
r Ilia basis for the alleged cx plion,Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any appl1Ca11l For per. SlIbJeetti the dppllCa111 tOa civil penally
of nut mored nfi hu red dollars IS 00i):
ALTER-DRAIN -WATER (EA.) 4.00
❑ I,as owl -r o property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
then sole comp, sa I,will do the work,and the structure is not
intended or offer d for sale(Sec 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code: Ills Contra o,'x License Law flocs not apply to an owner of
pngoertyw b1l or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 so.FT.PLooe AREA TOTAL ACREAGE
• himself or h his own employees,provided that such improve-
mentsa o mended or offered for sale.If,however,the building GAS-EA.SVSTEM-11NC.40UTLETS 4.00
or inlpro mem is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
build,,will have the burden of proving that he did net build or in-
prov,torPurpose ofs:de.) INDUSTRIAL WASTE INTER. 20.00 RES IND CON Pa oma
❑ I,as over of the properly.am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed a'of... rs w construct 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 dues 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 mntmctods)licensed pumumlt to
the Cun(oclors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am cxango under Sec.-,HAP.C.1,11 this WATER HEATER W/VENT 4.00
reason N
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE No.
W'ORKERS'COMPF,NSA'I ION DECLARATION WATER TREATING EQUIP. 4.00
hereby affirm Ihm I hove a cerlificate of consent to selGinsure. ZONING ENG.SITE NO.
or a certificate It Workcis CI mpensntion Imeoinee,or o certified
copy thereof(Sec.3800, b...
Policy No._��Co
O ❑ CcHilbU(Mvishe 4y untiss FIRESPRINK ENERGY T.24
Z Z 1.1011 ifje{IE it is led with the city inspection division. MISC.- REFER TO ORD. []y ❑ N❑ 'Y N❑
' cc y CER'I'IFICA'rt:OF EXEMPI ION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOODZONE A.L.U.C.
�_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
O_ O 1118, section need not be compl,ted if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
Z hundred dollars IS 10
0) )
U O 1 certify that in IIance of the work for which this per- QTY. MECHANICAL PE T FEE FEE SUMMARY
1L 1- mit is issued,1 alloy any person in any manner sn as to
U become xubjed t hs'Compensation Laws of California.
LU owe ALTER OR ADD TO MECH. 4,00 BUILDING
} rn NOI'ICh yo PI' .ANT: It,after making this Certificate of Es.
f" ? cre,ion,y< Ind become subject m the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions f he Labor Code, you most forthwith comply with FEE
U such pro ".runs or this permit shall he deenrod ovok d. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10pWC.RM.) 5.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
O 100,000 B.T.U.) 4.00
3097,Civ.C.i HEATING UNIT IT
Lender's Nama HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I c"tify it 11 read thlsappli,ationand state that the above VENTILATION FAN (SINGLE) 3.00
• inkonnation et. I agree 10 aomplY with aII city and county PLUMBING
ordinances nd �xtc laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hermby :ul I, epresental fives of this city to corer upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
.ho.r,c I n property for inspccl ion purposes.
(We Tec to save, indenmify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liubilit ies,judgments, costs and expenses which CONST.TAX
may in any w" merue against said City in consequence of thePERMIT ISSUANCE 3.00
gr: Ring sto R1MECH.CONT LIC.NO. MECH.
IVA4Cpl _^r To;nL TOTAL
Signor D e o p ca t/ o u me W
INSPECTOR COPY