8270 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
w2,(121 A 8270
NER'S P(f�}` PLAN CHECK VALIDATION
NAME Vallm FaShi PHdPEk )
YGiJ.W jC1011LW1 DTV. ELECTRIC PERMIT FEE
OUTLETS-SWITCHES-RECEP 10.00/1.00:
LIC.NO� noo J3_
LIGHTING FIXTURES 10.00/1.00
DRRACrons
ADDRESS PPLIANCES-RESIDENTIAL 4.00
AD ^/ t
PITON /- Z ' PANELS 10.00
DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
�r ENGINEER 0=71
&Vrie
0SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
E, 00ean IR3_Vd 4C) -ZIP EMP.METER OR POLE INS. 20.00
APPLICANT'S Ig CA MOTORS SEE FEE SCH:• /t
ADDRESS
$ SERVICE CHANGE 20.00
i o 0 0 1JMKJ.N F "VAM)RS DECLARATION TEMP.POLE 30.00
a 0 w1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y a N (commencing with Section 7000)of Division 3 of the Business and a G. LE T. PLG. M C .
Hoz Professions CoJy//n my license is in Tull force and ef(c t.
i o m Limnu lass♦.RJ-�Lic.Numbeys �Q,B,(�
o y Dat ' ♦JQn.7t' Contract., ()(j
a m Bl. D NG PERMI
IS
¢ a OWNER-BUILDER DECLARATION
A O a 0 INFORMATION
w ; a H U hereby al'finn thin I am exempt frwn the Contractor's License MISC.- REFER TO ORD VALUATION
$/FT.
R 0< Law for the following reason.(Sec 703 1.5,Business and Professions PERMIT ISSUANCE 10.00 /t -
Code:Any city or County which requiresa permit to construct,alter,
w ¢ ¢ FO improve,demolitih,or repair any atracture,prim to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
a m 0 requires the applicant for such permit to file a signed aW lnnteI, th I TOTAL SP
pVVU Y IT TO
X
he is licensed pursuunl w Bre provisions nt the Contractor's License -
H z Law(Chapter 9(commeneingwlth Section 7000)o(Division 3o1 the
¢
4 0 Business and Professions Codcl or that he is exempt therefrom and QTV. PLUMBING PERMIT FEE
re H m the basis for the alleged exemption.Any viola inn of Sect ion 7031.5 STORIES TYPE CONSTR.
ate _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollurs($500).):
:I ❑ I,as owner of the property,or my employees with wagesas 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 docs not apply to an owner of
property who builds or improves thereon,and whu does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE
I- • mems are not
hde ownemployees.fors.dc.I .provided that such improve- GAS-EA.SYSTEM-1 6.00
mems are nal intended or offered for sale.IL however the building
j or improvement is sold within one year of completion,tire owner- GAS-EASYSTEM OVER 4 (EA) 200 BUILDING USE
4 builder will have the burden of proving that he did not build . - . .
or int-
} prove for purpose of talc.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
' ❑ L as owner of the property,am exclusively contracting with El El El El Ellicensed contra dors to The
the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
)' and Professions of Code:The Contractor's License Law does not apply
I _ to tr owner of property who ratios or improves thereon.and who LAWN SPRINKLERS-OVER 51EA.) 1.00
!� con tmclssuch projects with a conlractod s)licensed pursuant to
' the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sar.-,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
I, ACC.DATE ACC FILE NO,
WORK ERS'COM PENSA I'ION DECLARATION WATER TREATING EQUIP, 5.00
I. I hereby affirm that I have a Certificate ore
usent to self-insure.
1 or a cert;Ica of. orkers' smpensation Insurance,or a certified - ZONING ENG.SITE NO.
copy t6er r
I,.
PDlicydrCK'A- iy
II Q erlifled ' cry sh ' FIRE SPRINK ENERGY T 24
Z Z Uificd Iso )h tie 'it pection division. MISC.- REFER TO ORD.
O pplicant Y ❑ N❑ Y ❑ NE]
V5 CERTIFIC Ali OI'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
r LU > COMPFNSAIION INSURANCE PLG.CONTR. LIC.NO. PLG. ❑ ❑N V ❑ N❑
n• O t'I'his section oced not he c nmicted i1' the permit is for one TOTAL V
I Z) Z. hundred dollars IS 100)or less.)
U O 1 certify that!In the perl'onnance of die work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued, I shall not employ any person In InY n anncnso u,c to N
O w ore sdsjecPm tire Workers Gt rep n-alien L w: d 6alilixniu.
O_ Daw APphCanl ALTER OR ADD TO MECH. 5.00 BUILDING
to NOI WE '1'O APPLICAN I! II,.11,, nak'ny this Certificate of Ex-
Z emptton,you shoot,[bee umu subject Io the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
previsions of the'Lubor Code, you must forthwith comply with FEE
' - U such provisions or this pormit shall he deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10)000C.F.M.) 6.00 SEISMIC FEE / Lp
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
I the performance of the work for which the permit is issued(Sea MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
_ Lender's Nanm 1
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC 5'I
I certify that I move read this application and state that tine above VENTILATION FAN (SINGLE) 4.00
I, • information n correct. I agree li comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to comply
with construction. and
d, hereby authorize representatives of this city to enter upon the BOILER-COMP(Over l00,0008TUl SEE FEE SCH. MECHANICAL
h- above-mentioned property for inspection purposes.
♦ (we) agree m save, indemnify and keep harmless the City of MISC. REFER TO ORD. /
Cupertino against liabfl gmenD, costs and expenses which CONST.TAX
In
in st Said City in consequence of the PERMIT ISSUANCE 10.00 t'
grant; Nrl MECH.r CONT. LIC.NO. MECH.PSS / S TOTAL TOTAL
x $i r of App ant/ContraQor etc
/ INSPECTOR COPY
t
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