9227 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENT]FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT ^^^n
ADDRESS PQ QAst BUILDING - ELECTRICAL-PLUMBING-MECHANICAL I�LGI
OWN R' _._.
PLAN CHECK VALIDATION
4NAME QTY. ELECTRIC PERMIT FEE - ,
ONE
morae Across � OUTLETS-SWITCHES-RECEP 7,x00/1.00 ouj
cw.No. LIGHTING FIXTURES 1Q,QO/1.00 u
noNRess R APPLIANCES-RESIDENTIAL 4.00
,r. {� 115 PANELS 10.00 DATE OF APPucnrloN
ARCHITECT ,r,t, t �a PLAN CHECK FEE P.C.NO.
OR Lr o0g c 0.NS'�S PANELS (OVER 200 AMP) 20.00
ENGINEER
I-C NO. SIGNS TRANS. 3.00
nRCR,OR END- SPECIAL CIRCUIT 5.00 PER MIT VALIDATION
DDRZIP TEMP.METER OR POLE INS. ' 20.00
APPLICANT'S (/•'�'
AGORsss MOTORS SEE FEE SCH. '
'• SERVICE CHANGE 20.00
'02
0o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 S
r Z w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
Q u (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT PLG. MECH.
U m z Professions Code,and my license is in full force and effect ❑
z o y - Li cense Class �-1 n Lie,Number
0 y-_ IJa[c�.� ComractorF�r
r
a x J BUILDING PERMIT
¢ ¢ w OWNER-BUILDFR DECLARATION INFORMATION
w ;LL 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD -
FLLoa Law for the following reason,(See 7031.5,11usinessand Professions PERMIT ISSUANCE • VALUATION $/FT.
io Code:Any city or county whichrequiresa permit to construct,alter, '
IS ¢ o improve,demolish,or repair any structure,priorto its issuance,also ELEC.CONTR. ❑C.N0. ELEC.
et
tt requires the applicant forsuch permit to file u signet)statement that TOTALLL (�
Awns he is licensed pursuant to the provisions of the Contractor's License t2 PERMIT TO
Hzi 1-aw(Chapter 9(commencing with Section 7000)ofDivision 3 of lire
s o Business and Professions Coded or that he isexenlpt therefrom and QTY. PLUMBING PERMIT FEE
S,
I- m lire basis for the ullegsd exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
Ate _ by any applicant for a permit subjects the applimnt to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(8500).)'
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
(heir sole compensation,will do the work,and the structure is net DGG.GROUP RES.UNITS
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AR EA,CONE. 5.00
Code. The Contractor's License Law does not apply to an owner of
property who builds or improves[hereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR ARBA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
melas are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 6-00
or improvement is sold within one year of completion, the owner GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder wth
ill have the burden of proving at Ile did not build or int- BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(See 7044,BusinessLAWN SPRINKLERS-11NC5 V.B. 600 ASSESSORS PARCEL NO.and Professions Code: plic 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 SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License L... TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,B&P C.for this WATER HEATER W/VENT 6.00
rcosmi
Owner Data WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENNATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to seff-mium,
or a certificate of Workers'Compensation Insurance,or a arlified ZONING ENG.SITE NO.
co py lhcrcof(Sec.3800,Lab.0).
Policy No. Company
O ❑ Continued Copy is hereby furished, RE SPRINK ENERGY Toa
Z 2� ❑ Certified copy is tiled with the city inspection division.
F O Applicant p, ��i MISC.- REFER TO ORD. Y NE] Y ❑ N�
N^ CERTIFICATE Or IiX IiMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE AL.UA.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO.CL PLG.
;(This section need not be completed if the permit is for one TOTAL Y❑ N� Y N�
hundred dollars is 100)or less.)
CJ O 1 certify that in the performance of the work for which this per- CITY MECHANICAL PERMIT FEE
FEE SUMMARY
EL mit is issued, I tot not employ any person in any mammy so to
W become subject to the Workers'Compensation Laws of Calitbrnis.
Date Applicant , ALTER OR ADD TO MECH. 5.00 BUILDING
>_ tan NOTICE TO APPLICANT: If,after making this Certificate of lix-
F_ j� carnation,you should become subject to the Workeri Compensation - APPLIANCE 5.00 PLAN CHECK
provisions of tie Labor Code, you must forthwith comply with FEE
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
I hereby affirm that stere is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
The perl'onnan. of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). H EATING UN IT(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 //{v.
I certify (list l have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
information 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 authorise representatives movesection city to enter upon the BOILER-COMP IOvei400000 STU)SEE FEE SCH. MECHANICAL
above-mentioned property for insP of this
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.
(J�Q+A7�$. R a e 7�a�kS TOTAL TOTAL
.� Sibna[hrre of Applicant/Contractor Date
INSPECTOR COPY