8262 APPLICANT TO FILL IN INFORMATION WITHIN''RED LINES`- USE BALL POINT PEN'ONLY
BU I LDING PROJECT I DENTIFICATI ON .- PERMITNUMBER, '
BUILDING APPLICATION & PERMIT
ADDRESS A(�
1 BUILDING -ELECTRICAL-PLUMBING-MECHANICAL R Z 6 2
OWNER'S PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
PHONE
NRM[RACT Rs UTLETS-SWITCHES-RECEP .10.00/1.00
LIGHTING FIXTURES 10.00/1.00
noNness TORs�38 � . ,7�{�C-r PPLIANCES-RESIDENTIAL 4.00
O PRo IE PANELS10.00 DATE OF APPLICATION
OR ell PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARCH OR
r
ADDRESS ENG, SPECIALCIRCUIT 5.00 PERMIT VALIDATION
zIP TEMP.METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH.
r SERVICE CHANGE 20.00 �(
00 o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
BE u I hereby affirm that 1 am licensed under provisions of Chapter 9
2 w ISSUANCE DATE
y
az (commencing with Section 7000)of Division 3 of the Business and
I' H m 2 Professions Code Cid ease Is in full fo f cl BLDG. ELECT. PLG. MECH.
License las Lie.Number
o F D Date Contractor i
OWNER-BU +` BUILDING PERMIT
' a w vt i ILDER DECLARATION
J,z ;A m 91 hereby SHE. OUR I em a einpt lrom�fc onlrac(or L'iceni,�'*�}'MISC.-Y�:'d'- -, :.pve-,,REEER-TD ORD c y INFORMATION
F LL o j Law for the following reason (Sec 7031 5,Busi a d P sfesaions -k PERMIT ISSUANCE VALUATION S/FT.
Code Any City or county which requires a permit to construct. 1�0- (D
m � ELEC.CONFER. LIC.NO.
BE Lo ic p improve,demolish,or repair any structure,prior to its issuance.also ELEC. ti•-y�
a wCLL requires the applicant for such permit 1.file a signed statement that TOTAt� •Jk/ PERMIT TO
m he is licensed pursuant to the provisions of the Contractor's License `�
� zQLaw(Chapter 9(commencing with Section 7000)of Division 3 of l he r `�
i 0 Business and 1'ntfassions Code)or that he is exempt therclrom and DTV. PLUMBING PERMIT FEE L�LtG 7 e2 A
r m the basis for the alleged exemption.Any violation of5ection 7031.5 STORIES TYPE ONS
s- by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) $,00
of not mare than five hundred dollars(S5001.):
❑ I,as owner of[lie property,or my employees with wagesas BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
ru
their sole compensation, will do the work,and the stcture is 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 SO.FT.ELOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
merits are notintended oroffered for sale,If,however,the building GAS-EA.SYSTEM-11NC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner-
, builder will have the burden of proving that he did not build or in,- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose ofsaleJ. INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ I,as owner of the property,am exclusively contracting wi Rt ❑ ❑ ❑ ❑ ❑
N licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.8. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
❑ lam exempt under Sec. ,B.&i'.C.for this WATER HEATER W/VENT 6.00
rea on
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKFRS'COMPENSA'FION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby attirn that 1 have a certificate of consent to'self-insure, n s or a certificate of Workers'Compensation Insurance,or a certified en, ONING ENG.-SITE NO,
copy llice I Sec 118810,0,La b.C�. (��►.c 3i' Nfqux '
rt,h "py k§b Y `e
_�Q. ❑ yr IllWc pYs rby uOshL �J ti .. FIRESPRINK ENERGYT;I9
Z Z Cert - Oled d i th f i pL Ipn dII n -. -
�pplirt'em r MISC.- EFER TO ORD.
-t_ _ - - r :❑.. N❑ V:❑ "❑
try CIiR CAFI.OI E%,SIPTIOh FROM WORKERS' S' •PERMITISSUANCE' - " ' '10,00 -FLOOD ZONE AILUc
LU > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. q.'. PEG
CL O 1'1'his section need not be completed if the permit is for one `. TOTAL 1-Y❑ N❑ r Ya:❑ N❑
':) Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the.work for which this pe" TY. MECHANICAL PERMIT FEE FEE SUMMARY.
IL 1- mit is issued,I shall not employ any person in any manner so as to "
if,
O L) become subject to the Workers Compensation Laws of California.
CL Dale Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} Us NOTICE 'I0 APPLICANT: If,after making this Certificate of Ex.
F 2 emption,you should becomesubject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code you must forthwith comply with 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 IQOODC.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the-perlbnnauce of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CA HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender;Name
Lender's Address HEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Icertify that lhave read this application and state thm t he above VENTILATION FAN (SINGLE) . 4.00
inlioniation is correct. I agree to comply with.1I city and county PLUMBING
ordinances and state laws relating to'building construction, and BOILER-COMP(3H.P.or100,000B.T.U.) 6.00
above-hereby authorise representatives forint of this city es enter upon the BOILER-COMP(Over 100,000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
gra •Of in,S permit MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
WIR:affr7Lmmrar= ate
INSPECTOR COPY '