C8573APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ONPERMIT
�' + APPLICATION &PERMIT
NUMBER
BUILDING
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BUILDING - ELECTRICAL -PLUMBING - MECHANIC
OWNER "S
NAME
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�1PRONE
DTV. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
✓
DATE OF APPLICATION
CONTRACTORS
AD, 4z .s'�,a.GTy
E NAC / LIC. NO.
UTLETS-SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
cONTRACTOR S �
ADDRESS
/p a Q�C%�0(J� Ih vRONE
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
RCHrtECT
OR ��
ENGINEER
/,Vv LIC. No.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCHESSPECIAL
ADDRESS ENG- ��D �O '.0,00
CIRCUIT 5.00
PERMIT VALIDATION
/i/ /1� /YLI LIO ZIP4W.211
r
J/
(
S��'J
EMP. METER OR POLE INS. 20.00
nPP"I1A1v�w/AGSC
42 3
MOTORS SEE FEE SCHM/
SERVICE CHANGE 20.00,
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
1 hereby, affirm that I um licensed under provisions of Chapter 9
Icon orencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license IS In full force and effect
Class 0.6Lie.Number
ISSUA eE DATE
BLDG.
El
ELECT. PLG. MECH.
El ❑ El
•Date.�� Contractorop
OWNER-BUILDF.R DECLA A'TICK
I hereby affirm that 1 am exempt from the Contractor's License
Law for the following reason. (Sea 7031.5. Businessand Professions
Code: Any city or county which requires a permit to construct, alley,
Improve, demolish, or repair any Structure, print Io i15 issuance, allo
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
BUILDING PERMIT „v
INFORMATION -
MISC. - REFER. TO ORD
PERMIT ISSUANCE 10.00
Er
VALUATION
0
$/FT.
L
ELEC. CONTE. LIC. NO.
ELEC.
TOTAL
PERMIT TO
DTV. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000) of Division 3 of f he
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
/ $ R
TVP CO R.
by any applicant for a permit subjects the applicant too civil penalty
of not more than five hundred dollanl$500).)'.
ALTER -DRAIN & VENT -WATER (EA.) 5.00
❑ L as owner of the property, or my employees with wages as
their sole compensation, will do the work, and tire
e structure is not
BACK FLOW PROTECTDEVICE 4.00
.
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 5.00
intended or offered for Sale (Sce. 7044. Business and Professions
Code: The Contractor's License Law does nor apply to an owner of
properly who builds or improves thereon, and who does such work
himself or though his own employees, provided that such impruve-
mcnts are nm intended or altered for sole. If, however. the building
FIXTURES - PER TRAP 5.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM - 1 1 NC. 4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
prove for purpose ofsole.).
❑ 1, as owner of the property, any exchiiisely contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB Other
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project (See. 7044, Business
and Professions Code: The Contractors License Law does not apply
to ;in owner of property who builds or improves thereon, and who
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts far such projects with a contractor(s) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ I am exempt tinder See.-, B &P.C. for this
o uSall
y\
WATER HEATER W/VENT ,..6.00
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORKERS'COMPIiNSAn6N DECLARATION
I hereby affirm Eliot I lyave A certificate ofconsent to sell' -insure.
or a certificate of Workers' Compen tion Ins,' ace, or a certifi•
ZONING
ENG. SITE NO.
-
copy thereof (Sec. 3g00e Lab.C.).
Policy No Company
FIRE SPRINK
Y❑ N❑
ENERGY T 24
`•,. Y❑ N❑
c
ye copy is hereb neished
CeNif apy Is f� d rich he city i1peoint division.
Applic;mt_(��7/!j/
MISC.- REFER TO ORD.
F
CI' IP VIEFROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A. L. u.C.
COM SATI NON
COMPENSATION INSURANCE"
III, Section need not be completed if the permit is for one
Y ❑ N❑
Y ❑ N❑
PLG. CONTE. LIC. NO.
PLG.
TOTAL
hundred dollars (5100) or less.)
I certify that in the performance of tire work for which this per-
mit is issued, I shall not anploy any person it any manner so us to
DTV. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
,b�
beconm subject to the Workers' Compensation Laws of California.
Date Applicant
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: IL after making this Certificate of Ex-
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
PLAN CHECK
FEE
emption, you should become Subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (OVER 10=C.F.M.) 6.00
SEISMIC FEE
' CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 5.00
I hereby affirm that there is a construction lending agency for
the perfannunce o1the work for which this permit is issued (Sec.
3097, Cv.C.).
MICROFILM
H EATING UN IT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address
H EATING UNIT (OVER 100,000 B.T.U.) 9.50
ELECTRIC
VENTILATION FAN (SINGLE) 4.00
I certify that l lwvcread thisapplication and state that the above
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
BOILER-COMP(3 H.P. Or 100,000 B.T.U.) 6.00
hereby authorize representatives nl'this city to enter upon the
above mentioned property for inspection purposes.
BOILER-COMP (Over 100,000 BTUI SEE FEE SCH.
MECHANICAL
(We) agree to save, indemnify and keep harmless the City of
MISC. - REFER TO ORD.
Cupertino against liobilities, .allP tS, costs and expenses which
A is an econe again si I City in consequence of tire
granting Ibis per tit. I
`,may!'`
CONST. TAX
- •
PERMIT ISSUANCE 10.00
MECH. CONT. LIC. NO.
r ""
MECH.
TOTAL
TOTAL
16to / Ie'
Signator ca / o raptor Date
INSPECTOR COPY -
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