C8226 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
i✓• 6/OL FE (' A226
A0Oness (' 6/1 BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 1p11
OwNEWSp +PLAN CHECK VALIDATION
NAME �f £v CITY. ELECTRIC PERMIT FEE
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Nome ACTORS C,tr 5260 OUTLETS-SWITCHES-RECEP 16.00/1.00 02
LIC.NO, LIGHTING FIXTURES 10.00/1.00 24^
CONTRACTORS RESIDENTIAL 4.00 /
ADDRESS .`
PHONE PANELS 10.00 DATE OF APPLICATION
• OORRcmTECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
r
ZIP EMP.METER OR POLE INS. 20.00
ADDRESS rS MOTORS SEE FEE SCH. S
APPLICA
SERVICE CHANGE 20.00
D a ZTEMP.POLE 30.00 µ/ (-�
_02 LICENSED CONTRACTORS DECLARATION / �7 J
`Ea,
u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
z.s (commencing with Section 7000)of Division 3 of the Business and
n _ LECT. PLG. MECH.
E. D z Professions Code,and my license is in full force and effect. \ ❑ ❑ ❑
z O o z License Class Lic.Number
O z F Dale Cnn tractor
a x BUILDING PERMIT
cr w ¢ OWNER-BUILDER DECLARATION ,l
wD A " MISC.- REFER TO ORD INFORMATION
.3 m I hereby affirm that I am exempt from the Contractor's License VALUATION $/FT
.. O-st . Law for the following reason.(Sec.7031.5,Businessand Professions
H i PERMIT ISSUANCE 16.00 �� U
Code:Any city or county which requiture permit tots issuance.
alter,
I[ ¢O .Improve,demolish,or repair any structure,prim to its issuance.'vlso ELEC.CONTE. LIC.NO. ELEC.
O LL requires the applicant for such permit to file a signed statement that TOTAL
u w ore PERMIT TO,y'
he is licensed pursuant to the provisions of the Contractor's License
Hzi Law(Chapter 9(commencing with Section 70001o1Division 3ofthe ,e
4 0. Business and Professions Code)or that he is exempt therefrom and Q _TY. PLUMBING PERMIT FEE t
¢ m•, the basis for the alleged exemption.Any violation ofSection 7031.5 STORIES :,TYPE CO TR.,•,
a ; ,- 'by any applicant lora permit subjects the applicant ton Civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollms(55001): T '
❑ 1,as owner of the property,or my employees trwith wages as BACK F LOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the sucture is not
intended or offered for.sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00 -
Code: flue Contractor' s License Law does not apply to an owner of .. %
property-who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SET FT FLOOR AREA TOTAL ACREAGE
timsell'or through his own employees.provided that such improve- GAS-EA.SYSTEM-11NC.40UTLETS 6.00
nems are not intended or offered for sale.If,however,the building
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
x prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON Other
❑ I,as owner ol'the property,am exclusively contracting with ❑ El E]
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL 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 SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sea ,B.&P.C.for this WATER HEATER W/VENT 6.00
,,a,,
Owner Date WATER SYSTEM 5,00 ACC.DATE ACC.FILE NO.
WORKFRS'CO,NPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby.(firm that I hove a certificate nl consent to sclfinsurc' ZONING ENG.SITE NO.
or n certificate of Workers'Compensation Insurance,or a ce Nified
copy thereof(Sec.3800,Lab.C.).
Policy No, Company
O ❑ Certified copy is hereby I'untished.
f IRE$PRINK EN ERGY T24
z Z ❑ nrtifed copy is fled with the city inspection division. o
� O Applicant MISC- REFER TO ORD. YE] ryvF] No
CC - CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG. V N Y N
Z (This section need not be completed if the permit is for one TOTAL
hundred dollars IS 100)or less.)
L) O 1 certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mitis issued.1 shall not employ any person in any manner so as to
OW become subject to the Workers'Cmppensmion Laws of California.
CL Dale Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W ,NO1'ICF. TO APPLICANT: If,after making this Certificate of Ex-
Z emplion,you should become subject to the Worker Compensation APPLIANCE 5.00 PLAN CHECK
prosworls of the Labor Code, you most I..IlIwith Comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 FEE ,rte a w r
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=CF.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC Q"C!
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 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 authorize representatives this or city to Inner upon the
tionbd BOILER-COMP(ONS,100,000 BTU)SEE FEE SCH. MECHANICAL
hereby auproperty for inspection on 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 aga' st said CI in consequence of the
granting this PC'R. MECH.CONT. LIC.NO. MECH.
40
5; of TOTAL TOTAL �'��O
ureo 7 c /Cont t Dace
f INSPECTOR COPY