C8539 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON PERMIT NUMBER
Bon LDING - APPLICATION & PERMIT �� .
ADDRESS
UILDING - ELECTRICAL-PLUMBING-MECHANICAL
W ER' PLAN CHECK VALIDATION
NAME '• PnorvE OTY. ELECTRIC PERMIT FEE
NAME/Acr ns OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR s �IOI,,,F,� gCqF.146�) PPLIANCES-RESIDENTIAL 4.00
11 �,W o _ PANELS 10.00 DATE OF APPLICATION
,- oRCHrr-_ PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO,
ENGINEER R
uc.No. SIGNS TRANS. 3.00 r
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP FrEMP.METER OR POLE INS. 20.00
APPLICANTS
ADDRESS
MOTORS SEE FEE SCH.
A
SERVICE CHANGE 20.00 •�
wo LICENSED CONT RACfORS DECLARATION TEMP.POLE 30.00
a i w I hereby affirm that 1 an licensed under provisions of Chapter 9 I$SUANCEOATE.
(commencing with Senior 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F w z Professions Code my license is in full fo ' eife ❑ ❑ ❑ ❑
License Class Lic.FwShe'
9 z,F off•' Dat Contractor
a Ie ac a NIS -BNLn1iR nECL Rn'f N BUILDING PERMIT
E o a INFORMATION
w g w I hereby affnm that I am exempt from the ontracmr's License MISC.- REFER TO ORD
VALUATION $/FT.
a_ o j Law for the following reason.(Sec.7031.5,Busincssxnd Professions 10.00
I- - PERMIT ISSUANCE
Code:Any demolish,
whiny structure,
P prior
its i snance.also j0/ OOP
IS ¢ ¢ o improve,demolish,or repair any structure,prior to its issrwnce,also ELEC.CONTR. LIC.NO. ELEC.
o ¢ requires the applicant for such permit to file a signed statement that TOTAL
K
m " he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
F i Law(Chapter'J(commencingwith Section 7000)of Uivision3of the
gi o Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE A/:TE'r2/O.Q 'MudC
¢ I- o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any uppli.nt for a Permit subjects the applicant to a civil penalty ALTER-DRAIN (EA.) 5.00
Of not Gino,than five hundred dollar'155000.1: -
O 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 Ile work,and the stnlalure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:'1'h,Contractors License Law docs not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 S0.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own anployees,Provided that such ingDrove.
nenls are not Emended orol'leedl'Or sale ll',however.the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or intprovenemt is sold within one Year of completion, the owner- GAS EASYSTEM OVER 4(EA ) 200
builder will have the burden of proving that lie did not build Or ice - . - . .
- BUILDING USE
Prove far purpose Of Sale.l. INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ I,as owner of the property,am cxelu.sively con Ducting with ❑ 0 ❑ ❑ ❑
licensed contractors to construct the project IS".7044,Business-' LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor,License Law docs not apply
to mI owner of property who builds or improve,thereon.and who LAWN SPRINKLERS.-OVER 5(EA.) * 1.00
contracts for such projects with a commilons)licensed pursuant to
the Contractor's License Law. I SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt tinder See `B.&P.C.for this WATER HEATER W/VENT 6.00
eason
Owner _ Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK IiRS'COM PIiNSA'IION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a cenificate of ern#iV to self-insure, ZONING ENG.SITE NO.
or a Certificate of Workers'Compensation Insurance.or a certified
copy thereof(See.3800 ('Soy 1. i
Policy Nrt Company-r(J�d(S/dp/i 0Q
Q O Certified copy is, filed fu 1. FIRE$PRUsK ENERGY T-24
z Z Certified copy is filed with the city' inspec ' n ivisiun.
ant MISC.- REFER TO ORD. Y ❑ N Y ❑ NE)
ccw IC, 'O P '., PR RS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W CO\ d' ATI h'INSURd Cfi'ORKEPLG.CONTR. LIC-NO. PLG.
EL Z (This weon need no be completed if the permit is for one TOTAL Y Q NEl Y ❑ NEI
hundred Jolla 00 es,.)
U O I certify that in t e performance of the work for which this user- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,'I shall not employ any person in any manner so az tO
become subject to the Workers'Compensation I.aws rf Calilomia.
U d \ DineApplicant BUILDING /gp-V
} m NOTIC1 _s'0- APPLICANT: If,after making this Certificate of 1!x- ALTER OR ADD TO MECH. 5.00 13
F 2 eruption,you Should become subject to the Workers'Compensation APPLIANCE 5.00 ,'PLAN CHECK
prov@ions of the Labor Code, you must 1'orthwilh comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 i
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 ' SEISMICFEE - C),
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 this permit is issued(Scc. '
3097,Civ.C.). ; HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM-
Lender's NameI HEATI NG UN IT(OV E R 100,000 B.T.U.)9.50
LCndcrS Address ELECTRIC
`\ I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 '
Ordinances
is correct 1 agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
Ordinances and smte laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above n untioned property for inspection purposes.
{ (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
It Cupertino against liabilities,I.m gine costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
it may In any way in against a City in consequence of the
gnmo of This >C yt. MECH.CONT. LIC.N0. MECH.
TOTAL TOTAL /o
`C
at e. A n om ,tor U c
,� INSPECTOR COPY