10145o c: W O O
q U U
rQa
N y
F y 2
ZO 2 w O
NFw
q Y E J
o-OaU
X 3 LL
F LL O J
N> -
Ir IcqW 2
W
Ir
rlXOLL
W m N
Y O
W H W
a 3 .-
0
Z
tY
LU -
C-
Z) Z
Uo
LL V
0W
N
A
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATION PERMIT NUMBER
l APPLICATION & PERMIT
BUILDINGADDRESS
1Dz. Crime BUILDING - ELECTRICAL- PLUMBING - MECHANICAL 101450'o z.
OWNER'S
1%/s PLAN CHECK' VALIDATION
NAME
QTY. ELECTRIC PERMIT FEE41d617Q . PHONELr7/-
CONTRACTOR'S
NAME OUTLETS -SWITCHES- RECEP 10.0011.00
L
d
j
CGfr G LIC.NO. J ,?6 LIGHTING FIXTURES 10.00/1.00o
X00CONTRACTOR'S 4,0056Lpqi/Q/G PPLIANCES-RESIDENTIALADDRESS
PANELS 10.00 p DATE OF APPLICATION
ARCHITECT
PANELS (OVER 200 AMP) 20.00 PLANGHECKFEE P,C.NO.
OR
ENGINEER
LIC. NO. SIGNS TRANS. 3.00
ARCH. OR ENG.
ADDRESS SPECIAL CIRCUIT S,QQ PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 20.00
APPLICANT'S SEE FEESCH, Oil
Av o & 1_e1// 000d t/ e, SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATI N TEMP. POLE PJIUD 30.00
1 hereby affirm that 1 am licensedunder provisions of Chapter 9 ISSUANCE DATE
commencing with Section 7000) of Division 3 of the Business and I BLDG. ELECT. PLG. MECH.
Professions Code, d license is in full force a F c
License Cl= Lin. Number
Date_,/
e Contractor
BUILDING PERMITi7CUertlnOOWNERBUILDERDECLARATIONINFORMATION
I hereby affirm that I am exempt from the Contractor's License MISC. - REFER TO ORD
VALUATION SIFT. Law for the following reason. (Sec. 7031.5. Business and Professions PERMIT ISSUANCE 10.00 V
Code: Any city or county which requires a permit to construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
ELEC. CONTR. LIC. NO. ELEC.
TOTAL 1 d a PERMIT TOf/ems!' a
he is licensed pursuant to the provisions of the Contractor's License
9 Division
f-
LZrL Law (Chapter (commencing with Section 7000) of 3 of the
Business and Professions Code) or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
STORIES TYPE CONSTR. the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant toa civil penalty ALTER -DRAIN &VENT -WATER IEA.) 5.00ofnotmorethanfivehundreddollars (5500).):
1, as owner of the property, or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC, GROUP RES. UNITStheirsolecompensation, will do the work, and the structure is not
intended or offered for sale (Sec. 7044, Business and ProfessionsDRglNS-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 FIXTUR E5 - PER TRAP 5.00 SCL FT, FLOOR AREA TOTALACREAGE
himself or through, his own employees, provided that such improve-
ments are not intended or offered for sale. If, however, the building GAS - EA. SYSTEM -1 1 NC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS EA. SYSTEM -OVER 4 IEA.) 2,00 BUILDING USEbuilderwillhavetheburdenofprovingthathedidnotbuildorim- RES INp CON PB Otherproveforpurposeofsale.).
1,
INDUSTRIAL WASTE INTER. 30.00 D El 13 0E? as owner,of the property, am exclusively contracting withEl
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 thcreori. and who LAWN SPR IN KLERS - OVER 5 IEA.) 1.00
contracts for such projects with a contractor(s) licensed pursuant to
the Contractor's License Law. SEW ERSAN ITARYSTORM EA. 200ftl1 0.00 TRACT NO. PARCEL NO.
1 am exempt under Sec. B.&P.C. for this WATER HEATER WIVENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC. DATE ACC. FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self -insure. ZONING ENG. SITE NO. or a certificate of Workers Compensation Insurance, or a certified
copy the f Sec. b,
Clfrtfp Policy
Certified copy ishereby furnished. FIRESPRINK ENEFIGYT•24
Certified co y Olery wLL cit ins ection division.
Aplicant
P,
Lj !/! r y C MISC. REFER TO ORD. Y 0 N v IN
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10,00 FLOOD ZONE A.LU.C.
COMPENSATION. INSURANCE PLG. CONTR. LIC. NO. PLG.
Y N Y [:] N
This section need not be completed if [hepermit is for one TOTAL
hundred dollars (S 100) or less.)
I certify shat in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
mit is issued, I shall not employ any person in any manner so as to
BUILDING
become subject to the Workers Compensation Laws of California.
Date Applicant ALTER OR ADD, TO MECH. 5.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
PLAN CHECKemption, you should become subject to the Workers' Compensation APPLIANCE 5.00
provisions of the Labor Code, you must forthwith comply with FEE
such provisions or III is permit shall be deemed revoked. AIR HANDLING UNIT (TO 109MC.F.M.) 4.00
SEISMIC FEECONSTRUCTIONLENDINGAGENCYAIRHANDLINGUNIT (OVER 10=C.F,M.) 6.00
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 (Sea
HEATING UNIT ITO 100,000 B.T.U.) 8.00
MICROFILM
3097,Civ.C.).
Lender's Name
ELECTRIC-
G
Lender's Address HEATING UNIT (OVER 100,000 B.T,U.)9.50
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 BOILER- COMP (3 H.P. 100,000 B.T-U.) 6.00
PLUMBING
ordinances and state laws relating to building construction, and or
MECHANICALherebyauthorizerepresentativesofIhiscitytoenterupontheBOILER -COMP (Over 100,000 BTU) SEE FEE SCH, above-mentioned property for inspection 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
ting of this pC MECH. CONT. LIC. NO. MECH.
8 TOTAL
TOTAL
Signature of App1t n1/Contractor Date
OFFICE COPY