8225 APPLICANT TO FILL IN INFORMATION WITHMARED LINES - USE BALL POINT PEN ONLY
PP
' INT
LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
RDNAPPLICATION & PERMIT
ADNESS
' BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 8225
OWNE 5 PLAN CHECK VALIDATION
NAME
QTY. ELECTRIC PERMIT FEE
NAAM[CONTRac oRs OUTLETS-SWITCHES-RECEP-1 .00
LIC.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIDNO. SIGNSTRANS. . 3.00
ARCH ORRESS ENG. SPECIAL CIRCUIT S.QQ PERMITVALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 1
pPPLILANT'E /I
MOTORS SEE FEE SCH.
ADDRESS /
• SERVICE CHANGE 20.00
'02 LICENSED CON'T'RACTORS LIECLARAT'ION TEMP.POLE 30.00
¢0 wI I hereby affirm that I am licensed underprovisionsof Clmpter9 ISSUANCE DATE
uHi a `w/ (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H y z Professions Code,and my license is in full force and effect
o z w o Lecose Class Lie,Number
Dwit Cnntruclor
Q Y J BUILDING PERMIT
¢ a OWNER-BUILDER DECLARATION
E o a 0INFORMATION
w 3 LL H I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
F u 0 Law for the following reason.(Sec.7031.5,Ifusincse and Professions PERMIT ISSUANCE�/ VALUATION $/FT.
Code:Any city or county which requirese permit to construct,.also
¢ ¢¢ p improve,demolish,or repair any structure,prior n its issuance,also ELEC.CONTR. LIC.N0. ELEC. O,
a- ECLL requires the applicant for such permit to file a signed actor's Li that TOTAL / PERMIT TO
w m ha is licensed pursuant(commencing the with
ofthe )Contractor's License
r z i the
Baw(Chand Prosinsode)or Suction is exempt of Division and
Business and Professions Code)or that he is exempt therefrom and QTV. PLUMBING PERMIT FEE 1 1 I
¢ I- the basis for the alleged exemption.Any violation n t ofSection o ction 703L5 STORIES TYPE CONSTR.; by any cusubjects the for permit subjecthe applicant to a civil penalty
of net more
than five hundred dollars(5500).): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 DCC.GROuv RES,UNITS
thin,side compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 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.FLOOR AREA TOTAL ACREAGE
himself re through his own emred for
provided thus such improve.
memsare
not mens is
or within,one year o lhowever.the building GAS-EA.SVSTEM-11NC.40UTL ETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
huilder will have the burden ofmoving that he did nut build or ins. BUILDING USE
Pr ve or purpose of sale.)' INDUSTRIAL WASTE INTER. 30.00 R 5 IND CON PB Omer
I,as owner of the property',am exclusively contracting with ❑ ❑ ❑ ❑
lic Is contractors to construct the project(Sec. 7044, Business LAWN SPRINKLERS- I INC 5 V.B. 6.00 yASSESSORS PARCEL NO.
and Professions Code:'Che Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPR INKLERS-OVER 5 (EA.) 1.00 '
contracts for such projects with a contractor(s)licensed pursuant to SEWER-SANITARYV-STORM EA.200ft/10.00
the Contruclor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Seo. ,B.&P.C.for duns WATER HEATER W/VENT 6.00
Ow"0r WATER SYSTEM 5.00
1 Date !;�_ / ACC.DATE ACC.FILE NO.
WORKERS'COMPEN'SATION DECLARATION WATER TREATING EQUIP. 5.00
,. I herehy affirm that I haul a certificate of consent toself-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NOT
copy thercof(Sce.3800,
Policy No. Company
O ❑ Certified copy is herehy furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is fled with the ail, inspection division. MISC.- REFER TO ORD.
O Applicant Y❑ N❑ Y ❑ IN F]
CBRTIFICA'I Ii OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE - A.L.U.C.
IL > CO,\IPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG,
d 0 ffhis section need not be completed if the peunil is for one TOTAL Y❑ N❑ Y ❑ N❑
:D Z hundred dollars IS 1001 or Is,,.)
U O 1 certify that in the performance of the work'Or which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued, I shall not employ any person in any manner so as to
0 Ubeanie subject to the Workers'Conipcnsution Lawsof California.
ED Date ApplicantBUILDING
} SO NOTICE TO APPLICANT': If,after making this Certificate of Ex- ALTER OR ADD TO MECH.
Z emption,you should become subject to the WorkerC Compensation APPLIANCE 5 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 10=121F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IQOWGEM.) 6.00 SEISMIC FEE 'v
1 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.CJ, HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read thisapplication and sWic That the above VENTILATION FAN (SINGLE) 4.00
information n correct I agree to comply with all city and county BOILER-COMP13 H.P,or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and stale laws relating to comply
with alOnSIrand c alY
hereby authorize representatives nl' this city to enter upon tha BOILER-COMP (Over 100,000 BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes. '+
(We) agree to Save, indemnify and keep harmless the Cir,of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and cepemes which PERMIT ISSUANCE CONST.TAX /
may in any way accrue against said City In consequence of fire
granting of this Permit. MECH.CONT. LIG NO. MECH.
✓�._ � " I' L TOT L / TOTAL
SlgRdlaant C t ac o[ 7 Uale 3
INSPECTOR COPY