8901 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJEC.T 1 DENTI FICATION _ PERMIT NUMBER
BUILDING APPLICATION & PERMIT O
AOOPEas lo�rei l�
a BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
WER'B PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
• �A•�CIK �n� PXONE
CONTRACTORS
NAME n UTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10,00/1.00
CONTRACTORS
ADDRESSPPLIANCES-RESIDENTIAL 4.00
�..;4,5. PHONE.:Vf-Vj53Z PANELS .10.00
DATE OF APPLICATION
RRCHITECT
OR
PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. " 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESSZIP TEMP.METER OR POLE INS. 20.00 PAID
ADDRESsia�}� MOTORS SEE FEE SCH.
�S e%41,-% SERVICE CHANGE 20.00 IAP R: II111986
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 /sl}V of'Cultlnu.
a v aa
1 hereby affirm that I am licensed under provisions of Chapter 9 c •S
Ig UANCE DATE
w G h (commencing with Section 7000)of Divisiva 3 of the Business and BLDG. ELECT. G MECH.
r o z Professions Cod.,and ryryy license is in full force a d e e t ❑ ❑ ❑
o 0 o License CI ss - l�Lic.Number
¢ sc I J Hato ��_Contractar
M ¢ w ¢ OWNER-BUILDER DECLARATION BUILDING P RMIT
D MISC.- REFER TO ORD INFORM ION
ie ; u N 1 hereby affirm that I am exempt from the Contractor's License SIFT
Fm0 J La for the following reason.(Sec.703 1.5,Business and Professio PERMIT ISSUANCE 10.00 VALUATION
T Code. oy city or county whictimquiresa permittoconstrucl at,
¢ ¢ ¢ o improve, emolish,or repair,any structure,prior to its issuO,also ELEC.CONTR. LIC.NO. ELEC.
u we M requires lh plicant for such permit to file a signed st ant Him TOTAL O
D ,r, he is licensed scant to the provisions of the Cont tor's License
rZ > Law(Chapter 9l mencingwith Section 7000) ivision 3 ofthe
f 4 o Business and Proles' ns Code)or(hat he is unit therefrom and QTY. PLUMBING PERMIT FEE -
IeI- $ the basis for the allege •xemplion.Anyvio on of Section 7031.5 1 STORIE TV ECONSTR.
d ; hyanyapplicuntm,ape itsdjeclsthe )plicant toacivil penally ALTER-DRAIN -WATEfl (EA.) 5.01
of not more than five],unit dollars( 00).):
❑ 1,as owner of the prop ty, my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC,GROUP ES.UNITS
their sole compensation,will do work,and the structure is not
intended or offered for sale ( . 044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Conlracmi s Lice Law es not apply to an owner of
property who builds or i roves there0 and W],O dOeS suC],Work FIXTURES-PER TRAP 5.00 D. SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his n employees,pro nit that such improve
ments are not inten or offered for sale.If, we vet,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00 �-
or improvement iold within one year of co m ion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will h the burden of proving that he did n _ olid or im BUILDING USE
prove for ose of sale.). INDUSTRIAL WASTE INTER3000 IND CON Pe Oman
. .
❑ I,as owner of the property,an exclusively contracting with ❑ ❑ ❑ ❑
licensed Contractors to c.attract the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL IN
and Professions Code:The Contractor's License Law does not apply 0.
to an Owner Of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. ,�• RACT N0, PARCEL N0.
.❑ lam exempt under Sec.-,8,&P.C.for thisIcal /
On ,WATER HEATER W/VENT 6.00
Olwner 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,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec,3800,Lab,C.I
Policy No.rZ5�' 4 Company Mme%
O ❑ Certified copy is hereby furnished.
Z Z ;WC ertified Opy is filed withou, c ity,inspeclion division. FIRE SPRINK ENERGY T�24
� O Applicant ��irsi/S�[al/�.-us. MISC.- REFER TO ORD. Y IN v❑ N❑
CC y CERTIFICATE?OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 /Q FLOOO ZONE AL.U.C.
L 1 COMPENSATION INSURANCE PLG.CONT .RLIC. . PLG.
CL 0 (This section need not be completed if the permit is for one Qf NOTOTAL V❑ N❑ y❑ N❑
::) Z hon dd011urs(S100)or lessI
U O I certr in the performance of the work for wh'- s per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,1 s I t employ any perso nanner so as to
O W hecome suhject to Ose 'C anon Laws of CBlilnrnia.
CL Dme Appf BUILDING
} CL NOTICE_ TO AI'P T: If,after making us etlificatc of Ex ALTER OR ADO TO MECH. 5.00
I- Z mnption,yo uld become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
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 100(10C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=1C.F.M.) 6.00 SEISMIC FEE
I hereby a I is a construction le 'sg•agCrtcy for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work or 12 rns0.ic.iggy_rd(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender' N,'� HEATING UNIT 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that 1 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-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives for ins inspection
This city es enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
hereby
above-mentioned property for inspection purposes,
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORO.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10,00 CONST.TAX
may in any way accrue against 'Id City in consequence of the
grantingo is permit MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signature of Applmant/Contnetor Date
OFFICE COPY
t