C8188 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTI FICA71PERMIT rvumBER
BUILDING APPLICATION & PER* 11
'ADDRESS j e
DI G -ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME
'- • _ OTY. ELECTRIC PERMIT FEE
CONTRACTOR'S
ff NAME ,,a OUTLETS-SWITCHES-RECEP 10.00/1.00
ly 'a+' ,LIC.NO. ( LIGHTING FIXTURES 10.00/1.00
CONTRACTOR',
ADDRESS H( PPLIANCES-RESIDENTIAL 4.00
0 IMONEAfDg PANELS 10,00 DATE OF APPLICATION
ORE P.C.NO.
RCHIT CT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FE
ENGINE
0 SIGNS TRANS. 3.00
ADDRESS NIG pp jOZ SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
123 �vof�i/� Oar/ IIP EMP.METER OR POLE INS. 20.00
APP CANT A/ J MOTORS SEE FEE SCH.
ADDRESS
CIS-7Ld.c/57r' SERVICE CHANGE 20.00
0 0 TEMP.POLE 30.00 �3/e'S'
0 o o LICENSGD CONTRACTORS DIiCLARATION
San,
law I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
a vAi (commencing with Section 7000)of Division 3 of the Business and BLD ELECT. PLG. MECH.
D z Professions Cade,and in,license is in full force and effect. f{
z o o - License Class ez Lic.Number ur�l>LyGEl 1:1
o m t w Date fe(y $6 Contractor &4 lK, I
a y E BUILDING PERMIT
.ar
06D OWNER-BUILDER DECLARATION INFORMATION
w3: r I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
` an a. o a, Law for the following reason.(Sec.7031.5,Businessand Professions pERM1T ISSUANCE 10.00 VALUATION g/FT.
Code:Any city or county which requires'a permit to construct,alter,
2 ¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC NO. ELEC. D V✓�
G LL requires the applicant for such permit to file a signed,nutcase that TOTAL / pERN1,TS0
n w m w he is licensed pursuant to the provisions of the Contractor's License
Hi> Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
r c the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE C N
I+ u3m by any applicant for a permit subjects tire applicant lon civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars 145001.):
❑ I,as owner of the property,or my employees with wages as
I• their sole compensation,will do the work,and tine structure is not BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS.
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
I. Code:The Contractor's License Law does not apply to an owner of
_ property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SQ.FT.FLOOR AREA TOTAL ACREAGE
• himsellor through his own employees,provided that such Iimprove-p_ ...ents are not intended or offered for sale.If.however,the building GAS-EA.SYSTEM-i INC.40UTLETS 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 im- BUILDING USE
Prove
for purpose ofsxleJ. RES IND PB Other
t ❑ 1,as owner of the INDUSTRIAL WASTE INTER. 30.00
property,am exclusively contracting with ❑ ❑ ❑ ❑
r- licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS ARCEL NO.
and it of nee ofCode,Tho Contractor's License Law dues not apply
to tr owner of property who builds t r improves thereon,and whet LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractorts)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. j TRACT NO. PARCEL NO.
❑ lam exempt under Sic.-,EL&P,C.for this WATER HEATER W/VENT 6.00
reason
'Owner Date WATER SYSTEM 5.00
f° ACC.DATE ACC.FILE NO.
WORKERS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00
i
I hereby affirm thahave t I a tiGcaI of c t to self-insure, ZONING ENG.SITE N0.
_ or a certificate of Workers' m at ion man e,or a certified
copy thereof(Sec.3 S0 b
Policy No I y
Q G:lil'icit p c y f nuke .
c L, FiRESPRINK ENERGY T@0
Y z O CerNfq• m) i/N ith t c Inspection division MISC.- REFER TO ORD.Applicant Y❑ N❑ Y ❑ N❑
~
= T _ CER ATI; PitXEAfPTION PROM N'ORKIiRS PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
-
W COMM ENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
Ev d O (This cion need not be completed it the permit is for one TOTAL Y El ❑ T Y❑ N❑
Z hundred Jolla,, )to Iess.l
U O I Celli the pertonnance of thework for which this per OTY. MECHANICAL PERMIT FEE FEE SUMMARY
s EL 1- mit is issued,I shall not employ any person in any manner so as to
U Ubecome subject to the Workeri Compensation Laws of California.
ED Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
SL 35[� OV
} ril NOTICE TO APPLICANT: If,after making this Certificate of Ex-emptio n,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
ro
pvisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this pennit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IQOOOGEM.) 6.00 SEISMIC FEE /C3
�- I hereby of ire that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
Cp the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lenders Name
NH EATI NG UNIT(O V E R 100,000 B.T.U.)9.50
Lander',Name ELECTRIC
1 certify that I have read this application and state 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-OOMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (over f00.000BTU)SEE FEE SCH. MECHANICAL
r above-rationed property for inspvctt urp ses.
(We) agree 1. s' indvan f and keep armless the City'of MISC.- REFER TO ORD.
Cupertino ago' %iI!i",,,(mLn ns, cos nd expenses which pERM1T ISSUANCE 10.00CONST.TAX
may in anysaid City n consequence of thegranting ti e MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Sign, re oon
f pplican/Ctractor - D3ate ,��/V
INSPECTOR COPY