8202 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING �C/,W-r NA q� APPLICATION & PERMIT
ADDRESS
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL8202
OWNER'S PLAN CHECK VALIDATION
NAME �38-y'y'!� TY. ELECTRIC PERMIT FEE
. 6E
CONTRACTOR S
�j OUTLETS-SWITCHES-RECEP 10.00/1.00
vO/F2ia2 ' ' -'Lo, LIGHTING FIXTURES 10.00/1.00
ADDRESS oR's PPLIANCES-RESIDENTIAL 4.00
CONTRA
G NGOCr, / -1 PANELS 10.00 DATE OF APPLICATION
ORRCHITEGT PANELS (OVER 200 AMPI 20.00 PLAN CHECK FEE P.C.NO.
O
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5.BB PERMIT VALIDATION
ZIP rrEMP. METER OR POLE INS. 20.00 /
avvucarvrs MOTORS SEE FEE SCH.
AOORE55
SERVICE CHANGE 20.00 /
02 LICENSED CONTRACTORS UF:CLARA'r ON TEMP. POLE 30.00
a u U I hereby affirm that I am licensed Under provisions of Chapter 9 ISSUANCE DATE
y , h (commencing with Section 7000)of Division 3 of the Business and BL ELECT. PLG. MECH.
F w z Professions Code and m license is in full force an effect
z 0 w - License Class Lic.Number'7.�/Z 1 ❑ ❑
9 w w Datc Contractor
El
P:
Y f BUILDING PERMIT
¢ a ¢ OWNf:R-BUILUF,R DECLARATION RATION
¢w 0 INFORMATION
K
I hereby affirm that I am exempt from the Contractor's License IMISC.- REFER TO ORD VALUATION SOFT,
FLLO ¢ Law forthe following reason.(See.7031.5,Blalllessamd Professions PERMIT ISSUANCE 10.00
3w0 Code:Any City Or ounty whiehrraµdnSapvvnit to construct,alter,
C���p/
¢ ¢ Q O improve,demolish�or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. A
K ca tenures the applicant for such permit to file a signed statement that TOTAL PERMITTO
ic
u w sem he is licensed pursuant to the prmisions of the Contractor's License -
F z r
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthc
- Q Business and Professions Codd or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢moo the basis(or the alleged exemption.Any'violation of Section 7031.5 ES vP ONS
ate _ by any applicant for a permit subjects the applicant toacivilpenalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
O I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their Sole compeneatimu will do the work,and the structure is not
intended or offered lot sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code The Contactor E 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 SO,FT.FLOOR AREA TOTAL ACREAGE
, . himself or through his own employees,provided that such....prove-
nt ..
minds are not intended o offered for sale.IL however.the building GAS-EA.SYSTEM-l 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 IEA ) 2.00
builder will have the burden of proving that he did not build or in - . (EA.
1l BUILDING USE
prove for purpose of Sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND C PB Other
0 1,as owner of the property',am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044.Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSOR PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves flueo, n-and who LAWN SPR IN KLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to SEWER-SANITAR V-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&BC.for this WATER HEATER W/VENT, 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.OATE ACC,FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I lave a certificate of consent 1010f moue. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec,3800,Lab.CJ.
Policy N0 COmp1
O ❑ Certified copy is hemb fu s Y4
j y� FIRE SPRINK ENERGY T
Z Z ❑ Cetlif. -copy is BI w h city iy pcIIton division.
O Applicant MISC.- REFER TO ORD, y❑ N❑ v ❑ N❑
~ w x PERMIT ISSUANCE 10.00
� - TII9CATIi OP EXEMPTION 1'RObI WORKERS* � FLOOD ZONE a.L.0 c.
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. pLG. L YE] N❑ y ❑ N❑
CL Z( This section Even Trot be completed if the permit is for one TOTA
hundred dollars IS 100)Or less.)
U 0 1 certify that in On performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- unit is issued,I shall not ml.ploy any person in any..tanner so as to
0U beconm subject to the Workers'Compensation Laws of California.
a Dare Applicant ALTER ORA DO TO MECH. 5.00 BUILDING '
} b NOTICE TO APPLICANT: If,after nmking this Cerfificatc of lix-
♦- ? emption,you should become subject to the Worker:Compensation APPLIANCE 5.00 PLAN CHECK
Provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10SMC.F.NL) 4.00 FEE w
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE 5O
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the 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
Lender's Address H EATI NG UNIT IOVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that 1 have read this application and Sun,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-COMPI3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP loser 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep handless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
"Iay,iE any way awr a against said Cily consequence of the
grant:.. of this perm(f � MECH.CONT. LIC.NO. MECH. 2
TOTAL TOTAL a' '57 7J
SI lure of AppBeISMICountractor Date
INSPECTOR COPY