8126 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
HU,LDING APPLICATION & PERMIT R" %
ELECTRICAL-PLUMBING-MECHANICAL V li 2b
* OWNER'((S Y'V PLAN CHECK VALIDATION
Nq E• CITY. ELECTRIC PERMIT FEE
CONTRACTOR
OCS ✓S�l LlG7�oNE
OR'S
• NqM / � // q UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO. L/ O LIGHTING FIXTURES 10.00/1.00
AON{1,Rgss/T'gOR I .(115-- /f/� APPLIANCES-RESIDENTIAL 4.00
'1 PHOE��Nq-144L'�J PANELS 10.00 DATE OF APPLICATION
OORCHiTECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR
ADDRESS ENG. SPECIAL CIRCUIT 5.O6A PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
i
Ars
ADDRESS
MOTORS SEE FEE SCH. t` /
DREss
SERVICE CHANGE 20.00 V I y I s i
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 r
a i w 1 hereby affirm that I dm licensed antler provisions of Chapter 9 ISSUANCE DATE
(eonino,r6ng with Section 7000)of Division 3 of Ili,[Insides,and
y a n y - BLDG. ELECT. PLG. MECH.
H w i Professions Code erul use is in full for
o i w w Licenso�Claz Lic.Number ❑
H m Contractor
H J Late-
a x fa BUILDING PERMIT
¢ ¢ w a OWNIi R-BUILDER DECLARATION RATION
0 o u INFORMATION
K
; n. y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORDPA
u O a Law for the following reason,(See.7031.5,Business and Professions VALUATION $/FT.
_ PERMIT ISSUANCE 10.00
ac a, Code:Any mulish countypair ichany reqstructurees .
permit loconsuan e,also
a
¢ ¢ 0 improve,demolish,or repair any shuclurc,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEG FEB 2j .F
is
requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n w ¢ he is licensed pursuant to the provisions of the Contractor's License /
FZQ Law(Chapter 9(commencing with Section 7000)ofDivieion 3ofthe
4 O
Business wird Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT yyp
¢ H $ the basis for the alleged exemption.Am'violation of Section 7031.$ I-f f f Cl IES TYPE CONSTR.
u ; _ by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(SSOO).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered Ior yule (Sec. 7044, Business and Professions
Code ROOF,AREA,CON D. 5.00
Code:'f he Contmetor's License Law docs nnl apply to an owner 01'
properly who builds or i...proves thereon,and who docs such work FIXTURES"PER TRAP 5.00 SO,FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
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 EASYSTEM OVER 4 IEA) 200
builder will have lire burden of proving that he did not build or im - . - . .
- BUILDING USE
prove for purpose of sole.). RES IND CON PB Omin,
❑ 1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts forsuch pmjedswioh a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contract.,',Licence Law. TRACT NO. PARCEL NO.
❑ tum uxempl under see ,B.dd'.C.for this WATER HEATER W/VENT 6.00
a\Ohl
Owner Date WATER SYSTEM 5.00 ACC.DATE ACG FILE NO.
WORK ERS'COM PENSA'IION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm OUR I have a certificate of consent to s,Inmvur,,
or a certificate of Workeri Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereot(Sec.3800,Lab.C.)Aaf wV S v
Policy No. 0111 any
❑ Ccrlitted cop ud.
FIRE SPRINK ENERGY T2
Z 2 n ❑ Cnrt" d�copw i. a ci - REFER TO ORD.
O r' Applicant Y ❑ N❑ Y ❑ N❑
W CIIRTIF[CA117 OI'E X E M 1']'ION['RO M WO R K ER S' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU �:, COhll'BN'SATION INSURANCE PLG.CONTE. LIC.NO. PLG.
0. O (Phis section need not be completed if the permit is for one _ TOTAL Y❑ N❑ Y❑ N❑
Z) Z hundred dollars(S100)or less.)
U O 1 cenily that in lire performance of the work for which this per- FEE SUMMARY
LL F mit is issued. I shall not employ any person in any manner so as to CITY. MECHANICAL PERMIT FEE
Ow become subject to the Workers'Compumuoion Laws of California. r)
Date Applicant BUILDING J
>_ ran NOI'ICIi'I'O APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
F Z erroron,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK -U?
provisions of the Labor Code, you most forthwith comply with FEE �"
U such provisions or this permit shall be demned revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00
CONS']'RUCI'ION LENDING AGENCY AIR HANDLING UNIT(OVER IQWOCEM.) 6.00 SEISMIC FEE S^U
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of lire 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
HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Name ELECTRIC
4r1 certify ohm I have read alis application and state tum Um above VENTILATION FAN (SINGLE) 4.00
infomation is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-CONI H.P.or 100,000 B.T.U.) 6.00
hereby authorise representatives of this city to enter upon tiro
above mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU[SEE FEE SCH. MECHANICAL
(We) agree to save, indenmify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino agar a h 'es,judgments, costs and cx rcnses which PERMIT ISSUANCE 10.00 CONST.TAX
may In un ay 'crone
against said Cit �-onsmlucnce of
gr m(o hhi.lheriRl MECH.CONT. LIC.NO. TMECH
OTAL
I TOTAL
hgnaturc of Applicant/Contractor Date
APPLICANTS COPY