8258 (3) ' APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDINGAPPLICATION & PERMIT
ADDRESS 8258
BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S - - PLAN CHECK VALIDATION
NAME H. / OTY. ELECTRIC PERMIT FEE
•
CONTRACTORS
r}�1�.7� 1i701IV UTLETS-SWITCHES-RECEP 10.00/1.00
NA E
LIC.No.?s&5f LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
\ZA,LsAPPLIANCES-RESIDENTIAL 4.00
ADDRESS 1Y `r-
..JJJ VVV 1N.N PANELS 10.00 DATE OF APPLICATION
A T T PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO. '
OP
ENGINEER
t UC.NO._ SIGNS TRANS. 3.00
AARCH OR DDRESS ENG SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 20.00
ANrS
ADDDRESDRESS V MOTORS SEE FEE SCH. r 'I UI kS
SERVICE CHANGE 20.00 f
f o 0 0_ LICENSED CONI RACTORS DECLARATION TEMP.POLE 30.00
< U TJ I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
o< H (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H w z Professions Code nd esu is in full force 1.
z o m - Lice.
Ia - Lic.Numbe ❑ �\
D z F Date Contract. ,
+.;¢ a s -- ' - - BUILDING PERMIT
".1t a w OWNER-BUILDER DECLARATION - INFORMATION
)x w 3 LL s- 1 herchy Afmai that I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION
upQ Law far the following reason.(See.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 SIFT.
� mas Coe:Any city or county which reyuiresa permit to construct,alter,
rt rt < improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. '
U_
requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a w m He is licensed pursuant to the provisions of the Contractor's License /
rzi
Low(Chapter Y(commencing with Section 7000)of Division3ofthe
a Business and I'rofesslons Code)or that he is exe...Pt therefrom and DTV. PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant Loa civil penalty ALTER-DRAIN& VENT-WATER IEA.) 5.00
of not more than five hundred dollars(5500).)'.
❑ 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 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 docs such work FIXTURES-PER TRAP 5.00 SO.FT FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such amp mwv
Rents are not intended or offered for sale.ll',however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
- or improvement is sold within one year of completion,the owner. GASEA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or int- - BUILDING USE
RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
0 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(See. 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 an owner a1'property who huilds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a romractods)l lCcosed pursuant to SEWER-SANITARY-STORM EA.20011/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ tum exempt under Sea ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACO.FILENO.
WORKERS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00
I herby affirm that I have a certificate efcunsenl to sell-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENO.SITE NO.
'0pY the e
Policy &i h i�Dl }.IT S T), p\ �
Q ❑ tll led c.p}'is hereby fir sled ` FIRE SPRINK ENERGY T-24
z Z Cert' 'opy 's J with [he city inspection clivi ton.
O Applicant (a``G 11(}�y Misc.- REFER TO ORD. Y ❑ N Y ❑ N❑
F' rn yr " 1 ;^ PERMIT ISSUANCE, .p a 10.00 , FLOOD ZONE at,.u.c.
!f Chi R'1'I FICA I'E 01:EXENI I'TION FROM WORK BRS' -
W > COMPENSA'TION INSURANCE PLG.CONTR. LIC.NO, PLG. YE] N❑ Y❑ N❑
CL O (This section need not be completed if the permit is for one TOTAL
::) Z hundred dollars IS 100)or less
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
1L l- mit is issued,I shall not employ any person in any manner so as to
U become sobject to lire Workers Compensvtjon Laws of California.
0 a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} 0 NOTICE TO APPLICANT: It.after making this Certificate of Ex-
�. Z_ caption,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 10,000C.F.M) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is B construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the perfunnunce of the Work for which this permit is issued(Sue. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
1 certify that I have read this application and state that the above VENTILATION'FAN (SINGLE) 4.00
• information is correct, 1 agree to Comply with all city and county PLUMBING
ordinances and slate laws relating to building construction, and J BOILER-COMPO H.P.or 100,000B.T.U.) 6.00
hereby xuthorixo representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
! above-mentioned property for inspection purpo us.
(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 t' of this permit MECH.CONT. LIC.NO. MECH.
111 AM 0 TOTAL Tn TOTAL
'i n turcol pPlcarl n :e r a (�
INSPECTOR COPY
II