8271 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS 8271���
ADDRESS CA
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2 e• BUILDING-ELECTRICAL-PLUMBING -MECHANIL
W E 'S PLAN CHECK VALIDATION
NAME OTV. ELECTRIC PERMIT FEE
PHONE 4J -02
NOMERAcroR's C-10 OUTLETS-SWITCHES-RECEP 10.00/1.00
II,r LIC.NO. 2, LIGHTING FIXTURES 10.00/1.00
r,
ADDRESS oRs p04 /xJr`ttll� (3L.
APPLIANCES-RESIDENTIAL 4.00
ADDRESS ll_>r
O PHONE _ PANELS 10.00 DATE OF APPLICATION
ARCHITECT0. PLAN(OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENc. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 20.00
AMOTORS SEE FEE SCH.
ADDDRESSDRESS
SERVICE CHANGE 20.00
Foo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
3 U V I hereby affnm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
m a w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H N z Professions Code.Iced my license is in full force and effect. ❑ ®` ❑ ❑
Z O O - License classC= Lic.Number Ei2 a '9 g b
0 m H Dulc '�-oContrucmr_r-�yes���
`F(1)'LI C.. BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARA�10\
A 0 a 0 INFORMATION
w LL vii I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
n0 J Law for the following ,..a.(Sec.7031.5,Business and Pro fesamn, PERMIT ISSUANCE 10-W eI
VALUATION S/FT.
Code',Any city or county which requires a permit to construct,alter, - -'
2 ¢ ¢ 2O inlpmve,demolish,or repair any Structure,prior.W its issuance,also ELEC.CONTR. ` - LIC.NO. ELEC. �1
A. o a requires the applicant for such permit to file aiigned,statement that TOTAL PERMIT TO
O�
w m he is licensed pursuant to the provisions of the Contractor's License
Hzi Law(Chapter 9(commencing with Section 7000) rDi0xion 3 of the
a Business and Professions Code)or that he is exempt therefrom and QTV. PLUMBING PERMIT FEE
¢ F$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
03 _ by any applicant for apermit subjects the applicant toacivil penally ALTER-DRAIN -WATER (EA.) 6.00
of not more than five hundred dollars(S500).):
❑ 1,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 for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:'1'Ire Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP -5.00 sa FT.FLOOR AREA TOTAL ACREAGE
• mores are Hot
hde ownemployees,for sale.
If,ed ever.hat the
improve- GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
me nes are not intended or offered for sale.If,however.the building
or(der will 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 not buil)or ice- BUILDING USE
prove 1, purpose orsale.), INDUSTRIAL WASTE INTER. 30.00 0 IND 0 PB Omar
❑ d as owner of the onstruct he project
Se contracting with ❑ ❑ ❑ ❑ ❑
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 Conbuilds i improv Law does not apply
to tr owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a eonlmaorlA Iittnsed pursuant to
the Contructnr's License Luw. SEWE R-SANITAR V-STORM EA.200ft/10.00 TRACT No, PARCEt.No.
❑ I am exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM - 5.00 ACC.OATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I helchy affirm that I have a eortifcute of consent to sclLin,aue, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
0 ❑ C-fifed copy is hereby furnished. FIRE SPRINK ENERGY T24
Z Z, 11O'NI/tificd copy is filed with the city inspection division. MISC.- REFER TO ORD.
0 - ^AP Ic:mt -_e rz ctr( Y❑ N❑ Y N❑
~ _� PERMIT ISSUANCE 10.00
LU CF:R'TI FIC CO IiPE SAEIO r'INS FROM WORKERS' FLOOD ZONE A.LUF.
W need not be completed
INSURANCE PLG.CONrR. LIC.NO. PLG. Y❑ N❑ Y❑ N❑
D Z hundred
action need not be completed if tire permit is for one _ TOTAL
hundred ty 11m,that(S 1the pe less)
U O 1 is issued,
,I shall
the to employ
of the work fnr which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL L) mit is issuede 1 shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California. '•
0 a Dam Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Es-
F 2 emption,you should become subject to the Worked 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 10MCF.M.) 4.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNITIOVER 10J000C.F.M.) 6.00 SEISMIC FEE
I hereby affirnh 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(Sue. MICROFILM
3097,CivC.). ! HEATING UNIT(TO 100,000 B.7.U.) 8.00
Lender's Name.
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC C2B-9
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 -
inlixmation is correct. I agree to comply with all city and county PLUMBING -
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city W 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 harmless the City of misc.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
in any way accrue against said City in consequence of the
grwr hg of lh' enniLp`�K OCw tr'ZEzi>21 e.13� MECH.CONT. LIC.NO. MECH.
'1 TOTAL TOTAL
I re f n on Tac e
INSPECTOR COPY