8420 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDINGAPPLICATION & PERMIT
ADDRESS
BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
\ OWNE 'S PLAN CHECK VALIDATION
Nt ONE QTY. ELECTRIC PERMIT FEE
•
NAMERacroRs OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No. LIGHTING FIXTURES 10.00/1.00 -
" roRs
ADDRESS .41S'
PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
Oa°H1 �, 11/C.. PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE v.c.No.
ENGINEER
uc.Na. SIGNS TRANS. 3.00
ADDRRESS E"c SPECIAL CIRCUIT 5.08 PERMIT VALIDATION
TIP EMP.METER OR POLE INS. 20.00
ADDRESS
AMOTORS SEE FEE SCH.
ADDRESS
r SERVICE CHANGE 20.00
° ¢
, 00 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
zw I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
vi¢ (commencing with Section 7000)of Division 3 ofthe Business and BLDG. ELECT. PLG. 'MECH.
H. w z Professions Code,and my license is in full force and effect.
i m o License Class Lic.Number
F 6
m r J Dale Contractor
¢ > � L BUILDING PERMIT
¢ ¢ w ¢ OWNER-BUILDER DECLARATION
a O a u INFORMATION
X g LL e- I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION
u O j Law&v the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 $/FT.
Code:Any city medically which requires a permit to construct,alter,
¢ ea Q �' improve,demolish,or repair any structure,prior to Its issuance,also ELEC.CONTR. LIC,NO, ELEC.
n wDLL requires the applicant for such permit to file a signed Statement that TOTAL PERMIT TO `
$ he is licensed pursuant to the provisions of the Contractor's License M
Rzi Law(Chapter 9(commencing with Section 7000)ofDiv¢ion 3 of the
- ¢ Business and Professions Code)or that he is exempt therefrom and QTV. 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(8500).):
❑ 1,as owner of the properly,or my employees with wages as BACK F LOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
sole compensation,will do the work,and the structures 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 F I XTUR ES-PER TRAP 5.00 sa.FT.PLooR AREA TOTAL-ACREAGE
• himsel ats re
through his own employees,provided evlsuch im[IIpvr
or anprrvedi ll is sold or withinoffered
onefor sale,
year
if,however-(hcbuwner- GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or im r 0 ill have
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 mol huild or am- BUILDING USE
RES IND CON PS Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ L c owner of the property,he exclusively contracting with ❑
and Pro contractors to The
the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
and Professions Code:The Conhaelor's License Law does not apply ASSESSORS PARCEL NO.
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5'(EA.) 1.00 1
contracts for such projects with a contractor(s)licensed pursuant to SEWERSANITAR Y-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO., PARCEL NO.
❑ lam exempt under Sec. ,B.&P,C.forlful WATER:HEATER W/VENT 6.00
reason
Owner Dale WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
- WORK Ii RS'COMPF:NSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirmthat l have a certificate ofeonsetlltoself-insure, ZONING ENG.SITE NO.
or a certificate of Workers Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.0 I
Policy No. Cormpamy
O ❑ Certified copy) 4mreby fun lu FIRE SPRINK ENERGY T 24
'Z Z Certified eery is Bletl itlr city inspection division. y
O Aj;cant % MISC.- REFER TO ORD. v � N� Y ❑ NE]
I- w PERMIT ISSUANCE 1-U-01 FLOOD ZONE AL.U.C.
LU CEkTI e O N ATIO ROM WORKERS'
W (eOM not be TION Rt NCE PLG.CONTR. LIC.NO. PCL LG. ❑ ❑ ❑ ❑
O hundred
section 10d not be completed it (he permit is For one TOTAL Y N Y N
� Z hundmd dollars($100)or less
V O 1 certify that in the performance of the work for whidt this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H..... mit is issued,I shall not employ any person in any manner so as to
C)
become subject to the Workers Compensation Laws of California.
C_ Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W N'OT'ICE TO APPLICANT': If,after making this Certificate of Ex-
Z - en,plion,you should become subject to the Worked Compensation APPLIANCE 5.00 -, PLAN_CHECK
provisions of the Labor Code, you most forthwith comply will, FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
N I hereby uffim, that them is a construction lending agency lot EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. - MICROFILM
3097,Civ C.). HEATING UNIT ITO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that l have lead this application and slate that the above VENTILATION FAN (SINGLE) 4.00 rt.
information is correct. I agree to comply with all city and county PLUMBING V U
ordinances and stale laws relating to building construction, and BOILER-COMP(3H.P.or100,0006.T.U.) 6.00 o
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection urposos.
(We) agree to save, indent'yy cep harmless the City of MISC.- REFER TO ORD.
. Cupertino v 'lD(bllilies tlgto ants costs and expenses which CONST.TAX
may m way a rue gad t ,d City in consequence of the PERMIT ISSUANCE 10.00
grand of this p it MECH.CONT, LIG NO. MECH.
TOTAL TOTAL
St ut ' pylic t/Contra Da e
INSPECTOR COPY