8781 (2) r
APPLICANT JO FjILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENT(FICATI
�-( QrC;r.iVcier QKGIL- `,PERMIT NUMBER UMBER
BDILDING APPLICATION & PER f
ADDRESS BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 8
78
e
OLQZO✓)
oRS PLAN CHECK VALIDATION
NAME plI )
OTY. ELECTRIC PERMIT FEE
• PHONE
NAME acTORs OUTLETS-SWITCHES-RECEP 10.00/1.00
i
LIC.ND. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS /� +
A / n � PHONE i10 PANELS 10.00 DATE OF APPLICATION
OR RECT - PANELS (OVER 200 AMP) ,20.00 PLAN CHECK FEE P.C.NO.
ENGINEER .�,
1 LIC.No. � SIGNS TRANS. 3.Of], t
ADDRESS rt ' ` SPECIAL CIRCUIT 15.00 PERMIT VALIDATION 4T
^'T ✓ ZIP EMP. METER,OR POLE INS. 20.00 f
AP s
ADDRRESSESS v MOTORS t SEE FEE SCH. ,J
�. •i �)j j6--- SERVICE CHANGE 20.00
` w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 /
I hcreby ofhnn that I u,,I liccnsod under provisions of Chapter 9 ISSUANCE DATE
'yzw (commencing with Section 7000)of Division 3 of Ore Business anA
¢ u BLDG. ELECT. PLG. MECH.
y i �`
H Professions Code,and my license is in full force and effect.
-i 0 m- License Class IR_ Lic.Number 's G t-x'1111
9 m 0 Date Contractor Tr
a - E ! ti
�q
¢ 0 w U owN1>R-BUILDER DECLA RA'I'IOIJ B1IN FORMATION
'w 3 A.
LL H I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u'oa Law for thefollowing reason.(Sec.7031.5,Business and Professions pERM1T ISSUANCE 10 VALUATION $/FT.
- N r Code:Anycily orcounty which requires a permit to construct,alter, a
m Q ¢ LIC
0 II11prOVe,demolish,Of repair any$t[Iletllle,pp0[IO I[5 6511a11Ce,8160 EELEC.CONTR. -NO- LEC.
�.n G¢ v,oirts the applicant for such permit to file a signed statement that TOTALP R TATO
wm L. he is licensed pursuant to the provisions of the Contractor's License
Hzi Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
¢ Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Section 7031.5 17filioFfIeS, lilyyp STE.
dam _ by any applicant for a permit subjects the applicant to a civil penalty gLTER-DRAIN&VENT-WATER IEA.) 5.00
of not more than five hundred dollars 1$500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCG GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
Yi intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP5.00
mSO.FT.FLOOR AREA ,TOTAL ACREAGE
•yy• himself or through his own employees,provided that such Improve-
entsarenotintendedoroffered for sale.If.however,the buildili� GAS-EA.SYSTEM .0
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 im �. BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND PB Omer
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑
licenved contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSO s AHCELNO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves Ihercon.and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
` contracts for such projects with a contract.,(,)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
C the Contractors License law. TRACT NO. PARCEL NO.
).' ❑ 1 am exempt under Sec. ,B.&1',C.for this WATER HEATER W/VENT 6.00
Ieas011
Owner Date, WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSAT'[ON D17CLARATION WATER TREATING EQUIP. 5.00 m
I hereby utfion that I have n certificate ofconsent to velGin'ure. - ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance.or a certified
copy Ihco of(Sec.3800,LaaC.).
Policy N'o. Company
Q ❑ Certified 'opy is hcrehy f ishcd. FIRE SPRINK ENERGY T-24
z Z Certified o is file wi the city inspection division. _
Q q' iCarl `�`��.., ` MISC.- REFER TO ORD. YE] N� v ❑ N�
CC y, �- �P� PERMIT ISSUANCE 10.
- CERTIIICATE OPIiSEAI EXEMPTION FR-5M FLOOD ZONE
LU COMPENSWION INSURANCE PLG.CONTR, LIC.No,
a Z IT'hi, section need not he connplete t if the permit is I., one TOTAL •'�.
1h hundred dollars($100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall no,employ any person in any manner so as to
a
become subject to tine Workeri Compensation Laws of California.
ED Date Applicant q ER OR ADD TO MECH. 5.00 BUILDING OQ
} N NOTICE TO APPIACAN'1': 11,after making this C,,tif icate of Ex150
-
F 2 emption,you should become subject to the Workers'Connpensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
V such provisions or(his permit shall be deemed revoked. AIR HANDLING UNIT(TO I0=C.F.M.) 4.00
ro
CONSTRUCTION LENDING ACENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE �-
I hereby affirm that there is a construction lending agency IDT EXHAUST HOOD (WITH DUCT) 5.00
the periormunce of the work I'or which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name H EATING UN IT(OVER 100,000 B.T.U.)9.50 �
Lenders Address ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 IN •
,•�� information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMM H.P.or 100,000 B.T.U.) 6.00
hereby au0uriee representatives of this city to enter upon the
above mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harn0ess the City o1MISC.- 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
'1^ granting of this perm i MECH.CONT. LIC.NO. MECH.
/
6- - f TOTAL TOTAL
Slgnat�ol'Appliwntn ��dntra� rhL>� Date
INSPECTOR COPY