C8702 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBERBURLDING - APPLICATION & PERMIT
ADDRESS `vnj •G)
BUILDING -ELECTRICAL-PLUMBING-MECHANIC L
m O R'S PLAN CHECK VALIDATION
NAME
OTV. ELECTRIC PERMIT FEE
P N
CONTRACTORS _ r
F NAME _ OUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00 -
r, N AADDRESS-- PPLIANCES-RESIDENTIAL 4.00
ANELS 10.00 DATE OF APPLICATION
EC / - PLAN CHECK FEE P.C.NO.
OR _/� �<r�' /Tv-=-1�/1 l s/.1_ PANELS (OVER 200 AMP) 20.00
ENGINEEr -(/-,1211
//,, - . / SIGNS TRANS. 3.00
X %Vr(-�
AS ENG.�� PERMIT VALIDATION
ADDRESS ��. -_�--� SPECIAL CIRCUIT 5.00
� [TEMP.METER OR POLE INS. 20.00
ADDRESS MOTORS
ADDRESS (,(�r�t.A.a.r_, o SEE FEE SCH.
SERVICE CHANGE 20.00,
Y woo LICENSED CONTRACTORS DEC ARATI ON TEMP.POLE 30.00 }�
Q
u U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
i H G n (commencing with lection 70003 Of Division 3 of the Business and BLDG. ELECT. PLG. MECH,
.YH H z Professions Cod• an m 'cense is in full fort an effe 1. ❑ ❑ ❑
z o w - License Class lee \umber
o z H o UateContractor
Nr -
a Y E TION BUILDING PERMIT
0 w NIi R-BUILDS LA INFORMATION
w 3 o u H 1 hereby aDirur that I am exempt from the Contractor's License MISC.- REFER TO ORD
u m VALUATION $/FT.
F LL o j Law for the following reason.(Sec,7031.5,Businessand Professions PERMIT ISSUANCE x$90f
Code:Any city or county which requires a permit to construct,alter, Y C
).2 R ¢2O dmprove,demolish,or repair any stmeture,prior to its issuunce,also ELEC.CONTR. LIC.NO. ELEC.
O 0 requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
y
n w m Ire is licensed pursuant to the provisions of the Contractor's License
1 •F z rt Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Ousiness and Professions Code)or that he is exempt therefrmn and DTV. PLUMBING PERMIT FEE
or I m the basis fill time alleged exemption.Any violation of Section 703 L5 STORIES I TYPE CONSTR.
by any applicant fora permit subjects the applicant to a civil penAy ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than fisc hundred dollars($500).):
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 4.00 DCG GROUP RES.UNITS
their sole compensation,will do the work,and tire st
e ructure is not
intended or offered for sale Ilea 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 does such work FIXTURES-PER TRAP 5.00 So,FT.FLUOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
nments are not intended or offered for sale.If,however,the building
or improvanom 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 m"ale.). INDUSTRIAL WASTE INTER. 30.00 REs w0 eo PB Omer
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSUFP PIARCEL NO.
and Professions Code:The Contractor's License Law does not apply
-�' to an owner of property who builds or improves thereon,and who LAWN SPR IN KLERS-OVER 5(EA.) 1,00
�. contracts for WCh projects with a contmctons)'licensed pursuant 10
the Commetori,1iccmw Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT No. PARCEL NO.
❑ I an,exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 6.00 '
i reason
�.1. Owner Lae WATER SYSTEM 5.00 ACC.DATE ACC.FILE N0,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby alfirm that I have a certificate of consent to self-insure, ZONING
or u cc,lificritc of Workers'Compensation Insurance,or a cerlified ENO.SITE NO.
c �yI�!(!t��{�.A hermanyr�/N./F`iii/
0 n1facd✓�'�hereby 1'with
z Zr _ ❑ efy FIRE SPRINK ENERGY T.Y4
E% mn fileH with Ih 'tY_ rftftS _vnmon.
O' Sppi!L.ntny-. - S�lj ���_ -, _ MISC.- REFER TO ORD. v ❑ N❑ v ❑ N❑
~ w ( � 1 1 PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
CERTIFI I•,E, I N 6RrN'ORKERS'
ILU C NPENSAT ON L' URANCIi �� �G.CONTR. - LIG NO. PLG. Y❑ N❑ Y❑ N❑
� Z (I his secsidn need not be comp eted f the permit is for one TOTAL
hundred dollars IS 100)or less.) s
i, U O 1 certify that in the performance of the work for which this per- DTV MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner so as to
become subject to the Workers Compensation Laws of California.
U Do Dam Applicant ALTER OR ADD TO MECH. 5.00 S- BUILDING 3 7
'} to NOTICE TO APPLICANT: IL after looking this Certificate of Ex-
m (_ 2 emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
f' 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 1Q000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT 10MO C.EM.) 6.00 SEISMIC FEE (00
I hereby aflinn that there is a construction IcnAing'agency for EXHAUST DOD(WITH DUCT) 5.00 '
the Ierf)tmnnce of the work for which this permit is issued(Sec, HEATING UNIT(TO 100,000 B.T.U.) 8.00 x MICROFILM
Lendcrt NudeHEATING UNIT 100,000 B.T.U.)9.50
Lenders AJdrexs ELECTRIC i
Icertify that l have read fills application andstate that the above VENTILATION FAN (SINGLE) 4.00
inintonationentree. I agree to comply with all city and county PLUMBING
� ordinanamces and state laws relating to building construction, and BOILER-COMPl3 H.P.or 100,0008.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP IOver,100.000 BTU)SEE FEE SCH. MECHANICAL
above-Rmenl Toned property for inspection purposes.
$' (We) agree to save, indemnify and keep Inrmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs an expenses which PERMIT ISSUANCE 10.00 v v" CONST.TAX
may in aP ay accrue against said City i nSSequ_ence of the
r is i1, tl(j5.oermiL��- ---,� �-� MECH.CONT. LIC.N0. MECH.
TOTAL /S-h TOTAL
✓ aym -er A'ppbe�a-rfCOra eta -I sere---,-
/ INSPECTOR COPY
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