8184 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
aO,LDmG APPLICATION & PERMIT ��
ADDRESS 1/0 Nr Dc An1ZA 13i\/L)' -
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S
48
NAME PLAN CHECK VALIDATION
M0131L, 01L. 027•PHONE 2 5-3732 OTY ELECTRIC PERMIT FEE
NOM>EEAcroR's GT/RIL UTLETS-SWITCHES-RECEP 10.0011.00
�'rC.ELL
LIC.No.CIp� Z LIGHTI NG F INURES 10.00/1.00 •e -
ADDREScrORss APPLIANCES-RESIDENTIAL 4.00
ODREsp.0•T3px 20G0
pyl- PRONE PANELS 10.00 DATE OF APPLICATION
ARCHITECTI PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER „ice
LIc.No. SIGNS TRANS. 3.00
~ ADDRESS ENO I_ SPECIAL CIRCUIT 5000 PERMIT VALIDATION
ZIP E P. METER OR POLE INS. 20:00
APPucarvrs
ADDRESS ffes•�- S'IXJT MO ORS SEE FEE SCH. - S
IO7�J , IrI
SERVICE CHANGE 20.00
,w woo LICENSED CON'I'RAC'I'ORS DECLARATIONTEMP.POLE 30.00 S`
a v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
I a w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
o z m o Professions Code,and my license is in full force and affect. ❑ ❑ ❑ ❑/
z o w- License Class_4•0ry Lic.Number
L H w Ua¢ 4 (-S3- Contractor
Q Y J
a w� OWNER-BUILDER DECLARATION BUILDING PERMIT
0 A - MISC.- REFER TO ORD INFORMATION
-w 3 LL H 1 hereby affirm that 1 am exempt from the Contractors License VALUATION
- H u o`� Law I'or the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE ,D•00 $/FT.
,A0 Code:Any city'or county which reyuiresu permit to construct,alter,
ar Q Q p Improve,demolish,or repair any structure,prior t0 Its Issuance,also ELEC.CONTE. LIC.NO. ELEC. -
yQ O ¢ requires the applicant for such permit to file a signed statement that TOTAL
w mriche is licensed pursuant to the provisions of the Contractor's License - PERMIT TO
H z ar Law(Chapter 9(Commencing with Section 7000)of Division 3 ofthe EGc�
f z o Business and Professions Code)or that he is exempt therefrom andQTY. PLUMBING PERMIT FEE
$ the basis for Hix alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR,
ca by any applicantfor a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(5500).):
O 1;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 the work,and the st mature is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractors License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SCL FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
ments are not intended or offered for sale.If,however,the budding GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS EASYSTEM OVER 4 (EA) 2.00
builder will have the burden of proving that h - . - .
e did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES IND CON Pe Omer
Cl 1,as owner of the property,am exclusively contra . .
contracting with ❑ D ❑ E) ❑
lecivad contractors io construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Comnctor'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
currier,Ior such projects with a contraclorts)licensed pursuiuu to
the Contractor's License Law. SEWER-SANITARY-STORM V-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this
rcasn WATER HEATER W/VENT 6.00
n
Owner Date WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of'u"col to slf-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO,
copy thereof(See.3800,Leb.CJ.
Policy No. Company
O ❑ Certified copy is hereby furnished. RE BPRINK ENERGY T}4
Z Z ❑ Certified copy is filed with the city inspection division. ❑
FO Applicant MISC ❑ N ❑- REFER TO ORD, v v N❑
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE a.L.U.C. -
LU > COMPENSATION'INSURANCE PLG.CONTR. LIC.NO, PLG.
CL o (This section need not be or bled if the permit is for one TOTAL Y E] NE] Y❑ N❑,
::) Z hundred dollars IS 100)or less.)
) 0 1 certify that in the performance of the work tier which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
IL H ,mil is issued.1 shall not amploy any person in any manner so as to
U become subject to the Workeri Compensation Laws of California.
Ul O a Dale=npplleant - - ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOT F PPLICAN'l': If,after making I us CCr iNade of Ex-
1..- Z emption,you should became subject to the Workeri Compensalion APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I herebyaffirm that there is a ronstraction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
to performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Landcr's Nan.e
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
• I 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 PLUMBING
ordinances and state laws relating to building construction, and BOILER-OOMP(3 H.P.or 100,000 B.T.U.) 6.00
of h
hereby authorize representatives this city enter upon tire
hereby authored property for inspection purposes. e BOILER-COMP (Chair,tOQODO BTU)SEE FEE SCH. MECHANICAL
es
(We) agree to save, indemnify and keep harmless the City it MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way acctme against said City in consequence of the
gra lin"of thi acct
MECH.CONT. LID.NO, MECH.
TOTAL TOTAL
Si at. of Applican Contractor a[e
INSPECTOR COPY