8201 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
ROnDDINDIN
G APPLICATION & PERMIT ��
ADDRESS
1S 24- / BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
O IN 'S PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
• PHONE
NAMFR cTo s OUTLETS-SWITCHES-RECEP 10.00/1.00
uc.No. 7LIGHTING FIXTURES 10.00/1.00
ED
ADDRESS B APPLIANCES-RESIDENTIAL 4.00
ARCIbATPHONE '7 V PANELS 10.00 DATE OF APPLICATION
AECr T T
OR PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00
ADDRESS eNe. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zlv EMP.METER OR POLE INS. 20.00
ADDDRE55TS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
D ¢ TEMP.POLE 30.00
F O o hICENSIiD CONTRACTORS DECLARATION
F E,w I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
(cnnnnennng with Section 7000)of Divi,nm,13 of the Business and
Q n BLDG. ELECT. PLO. MECH.
w i 1'nrl'ese CII Code,and my license is in full force trod effect. ❑ ❑ ❑ ❑
oi m o Date sc Class C.R Number
m r Dale Contractor
a „ EBUILDING PERMIT
¢ ¢ firBUILDINGDECLARATION to INFORMATION
w5 u w I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
H LL a. to Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Fwto Code:Any city or county which reyuiresa permit toconstrucLalter,
¢ ¢ Q O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC
ar u requires the applicant for such permit to file a signed statement that TOTA.L
u w m m he is licensed pursuant to the provisions of the Contractors License PERMIT TO
Fi >
Law(Chapter 9(commencing with Section 7000)ofUivision Softhe
E 4 o Business and Professions Code)or that he is exempt therefrom and
¢ ti the basis fiir the alleged exemption.Any violation of Section 7031.5 QTV. PLUMBING PERMIT FEE
STORIES - 'TYPE CONSTP,
by any applicant for a permit subjects lhcallilicantto a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more them five hundred dollars(S500)J:
❑ I,us owner of the property,or my cm pbyccs 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,AREA,COND. 5.00
Code:'File Contractor's License Law docs nor 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 improve-
mentsara not intended or offered for sale.if,however,the building GAS-EA.SVSTEM-1 6.00
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 ire- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 5 IND CON PB amts,
❑ I,as owner of the property,am exclusively contracting will, ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sea 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to un owner,of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
etiinnists for such projects with u contractual)licensed pursuant to
rhe Contonenr's License Law, SEWER-SANITARY-STORM EA.200tt/10.00 TRACT NO. PARCEL NO.
O IunPxempt under Sec. ,B.&P.C,for this WATER HEATER W/VENT 6.00
Owner Data WATER SYSTEM 5.00 ACC.DATE ACG FILE NO,
WORK 17RS'COMPRNSA-1ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers Compensation Insurance,or a certified ZONING ENG.SITE NO,
copy thereof(Sec.3800.Lab.C.l.
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T24
Z Z ❑ Certified ca filed withQlu city inspection division.
FO Applicant �efL-�^�yLe.-pti--� MISC.- REFER TO ORD. Y ❑ IN Y ❑ N❑
cc CE RTI FI CAT E OF EX EAI 11'1'10N 17 ROM WO R K E RS' PERMIT ISSUANCE 10.00 FLOOOZONE A,L.UC.
LU > COMPENSATION INSURANCE PLG.CONTE. LIC.N0. PLG.
fl Cl ('Phis section need not be completed it tire permit is for one TOTAL Y❑ N❑ Y ❑ N❑
� 2 hu..died dollars(S1001or less.) I,
U O 1 certify that in fire performance(it tire work for which thin per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
U_ U ran is issued,1 shall not employ any person in any Inum r, so es m
Obecome subject to the Workers'Compensation Laws of California.
tD
0. Date-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE 'f0 APPLICANT: If,after..raking this Certificate of Ex-
F Z_ emption,you should become subject 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=11F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I 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.CJ. 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 Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
infonnarion is correctd agree to comply with all city and county PLUMBING
ordinances and state laws rcluting to building construction, and BOILER-COMPOH.P.or100,000B.T.U.) 6.00
hereby mirepresentatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
u boveanenfrmcd 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
granting of this permit MECH.CONT. LIC.NO. MECH.
SrgAF`Ap' a `,rr °T -l/e TOTAL TOTAL C-
J
INSPECTOR COPY
- I