8386 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFI CATION PERMITNUMBER
BUILDING APPLICATION & PERMIT ^
ADDRESS - _ BUILDING-ELECTRICAL-PLUMBING-MECHANICALQ. t-
ER' PLAN CHECK VALIDATION
T Na ME �.c NSL(=•C OTY. ELECTRIC PERMIT FEE L,L
• PHONE
enMmacroBs UTLETS-SWITCHES-RECEP 10.00/1.00 s
r 43 UCC NO, LIGHTING FIXTURES 10.00/1.00
CONTRACTORSPPLIANCES-RESIDENTIAL 4.00
RESS
ADDq Q' O0
3 L PHONE PANELS 10.00 DATE OF APPLICATION
RCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.ND. SIGNS TRANS. 3.00
ADDRESS SPECIAL EN SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.I
ADDRESS
t SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a U 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
aHi< Bc (commencing with Section 7000)of Division 3 of Ih,Business and BLDG. ELECT. PLG. MECH.
Z F w z Professions Code.and my license is in full force and effect.
o m- License Class
4 :Lia
Numb
❑ ❑ Elq Y Date Contractor BUILDING PERMIT ❑
a a a OWNEK-BUILDER DECLARATION
o a v INFORMATION
X 3 LL I- I hereby atfinn that 1 am exempt from the Com,acuar�
License MISC.- ) REFER TO ORD VALUATION
.. ors Law lot the following reason.(Seo.7031.5,Business and Professions PERMIT ISSUANCE � 10.00 S/FT.
Coda Any city or counly'which requiresa permit locunstruct,alter, /1
aa < o improve,-demolish,or repair any structure,prior to its issuance,also ELEC.COR`�NT 'i LIC.NO. ELEC. / �) /)9
0
S m u requires'Ilse applicant for such permit to file a signed slmalnent thin W TOTAL PERMIT TO
A w he is licensed pursuanm nl
t the pusvisum,of the Cor clor,License - t
H z i
Law(Chapter 9(commencing with Section 7000)of Division 3 of-the f
a Business and Professions Cade)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE /Ce✓/1 / r0 G�yE/
Q r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n ; m by any applicant for a permit subjects the applicant too civil penalty I -
ofnotmorethan five hundred dollimS(5500).); ALTER-DRAIN&VENT-WATER (EA.) 5.00 l
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 Oee.-GROUP RES.UNITS
their sole compensation,will do the work,and the structure I,not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,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 SD.FT.FLOOR AREA TOTAL ACREAGE
• - meats are throughhisor flared for sale.
If.ho ever,the
improve- GAS-EA.SYSTEM-I 6.00
meets are not intended or offered far sale.If,however,the n'prove-
or 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 nr in,. RES IND CON PB Orae.
Prove forof sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
❑ 1,ass comer owner of the properly,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
- and Professions Code:1'he Contractor's License Law docs not apply
In un owner of property who builds or immoves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts lot Such projects with o contmetorfs)licensed pursuunl 10
the Contracwr's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
O Iant cxcnrpt order Sri.-,B.&P.1-In,this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORT;ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconsenl to wif-insure. ZONING ENG.SITE NO,
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sce.3800,I.ab.C.),
Policy No. Conrpan
0 ❑ CcNifrede-py is hereby umish FIRE SPRINK ENERGY T�24
z ZO 1.g Cn1tified copy is filed with the city inspection Division. MISC.- REFER TO ORD. Y ❑ N❑ Y❑ N❑
Hy t1��L' o PERMIT ISSUANCE 10.00 FLOOOZONE A.L.uC. i
CIiRT119I o Of Ii XIvn NIIIII ON 1'R 61 WORKERS'
LU > COMPENSATION I NSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This Section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
Z) Z hundred dollars 1S 100)or less.)
U O_ 1 certify that in the perk nrnran"ol'the work Iowhlch this per. OTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is Issued,I shall not employ any person in any manner s0 as to
Ow become subject to the Workers'Compensm ion Lrwsof Caldonia.
C. Dam Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
W NOTICE 'f(1 APPE CAN'T': If,after making this Certificate of lin.
♦- ? eruption,you should become subject to the Workers'Compensution APPLIANCE 5.00 PLAN CHECK
provisions of lite Labor Code, you most forthwith Comply with FEE
U such 00
provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10, DC.F.NL) 4.00
CON'STRUCT'ION LENDING AGENCY AIRHANDLING UNITIOVER I0.000C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITHFDUCT) 5.00
the performance of ore work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ, HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lenders Name H EATI NG U N IT(OVER 100,000 B.T.U.)9.50
Lender's AAJre« ELECTRIC
I certily that I hava,cad this application and slat,that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to Comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.1 6.00
hereby authorise representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property forinspection purposes.
(We) agree to save, indemnify and keep harmless the City of Misc.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may In any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
-meting of this p MECH.CONT. LIC.NO. MECH.
�. e"T` TOTAL
/ }moo , c.t_o 1:s f-- TOTAL Oa
Signu�It v, M T'plic antra,or Ute �U
INSPECTOR COPY