8286 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING LcT LICATION & PERMIT
ADDRESS
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 8286
OWNER' PC ^ '
NAME C� 1 .`Wrr'.HO �`'•"'�L'"^'�2' OTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION
PHONE
COtTNA E °r°R OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO, LIGHTING FIXTURES 10.00/1.00
ADDRESS
CON TRACTORS PPLIANCES-RESIDENTIAL 4.00
AD
PHONE PANELS 10.00 DATE OF APPLICATION
ARRCHITECT PANELS IOVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
o. Q SIGNS TRANS. 3.00
ARCH.OR ENG. G PERMIT VALIDATION
ADDRESS 1��2rD S• S421iT'o4A�1uvinyuE. SPECIAL CIRCUIT 5.00
iI EMP.METER OR POLE INS. 20.00
ill ESS $, /hA-Q,y AVS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
0 o a LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a o U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w Q w (commencing with Section 7000)of Division 3 of the Business amt BLDG ELECT. PLG. MECH.
F w z Professions Code,and my license is in full force and effect. ❑ ❑ ❑
z o m - License Class - Lic.Number
w Late Contractor
r f UILDING PERMIT
Q w4 OWNER-BUILDER DECLARATION INFORMATION
wg LL H 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
LLOj Lawfor the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION SIFT.
� - 0 Code:Any rayorcounty which requires a permit to construct,alter,
improve,demolish,or repair an structure,prior to its issuance,also ELEC.CONTR. LIC.NO.
BE
Q ¢ p P P" Y P ELEC.
O BE requires the applicant for such permit to file a signed statement that TOTAL ER IT O
was he ilicensed pursuant to the provisions of the Contractor's License
FZi Law.(Chapter 9(commencing With Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is esees pt therefrom and OTY. PLUMBING PERMIT FEE
T r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIE1 TYPE'CONSTFI.
ate - by any applicant for a permit subjects tire applicant too civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00 I
o no ore than five hundred dollars(5500).):
as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
ole compensation,will do the work.and the structure is not OCC.GROUP RES.UNITS
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 Torg ACREAGE
himself or through his own employees,provided that such improve-
mentsare not imendedoroffered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner. GAS-EA.SYSTEM-OVER 4(EA.) 2.00 auILOING USE
builder will have the burden of proving that he did not build or im-
p ve for purpou ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PS Other
I,as owner of the Property,am exclusively contracting with ❑ ❑ ❑ ❑
li It ed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
y and Professions Code:'1'lie Contractor's License Law dues not apply
f to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant Io SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL N0.
❑ I in exempt under Sec .B.&P.C.lir flus WATER HEATER W/VENT 6.00
anon
Owners Dme WATER SYSTEM 5.00 Acc. E Ace FILE No.
W RKflk 'C htic: n'rl nHca.n kn lTON WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consult to sell-i
or a certificate of Workers'Compensation Insumme,or a eertil'knsure' ZONING ENG.SITE NO.d
copy thereof(Sec.3800,Lb.C.L -
Policy No. Company
O ❑ Certified copy is hereby l irniFhed. FIRE SPRINK ENERGY T24
Z Z ❑ Certified copy is filed with the city inspection division.
o Applicant MISC- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
~ w PERMIT ISSUANCE 10.00
lr - CERTIPICATEOPIA% I N IPROh1WORKIikS• FLOOD ZONE A.L.U.C.
CL COd ,Or be cON'INSURANCE PLG.CONTR. LIC.NO. PLGCL 0 . Y❑ N❑ Y ❑ N❑
� Z (This section need not be completed it' the pennil is for one TOTAL
hundred dollars IS 100)nr less,)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
UL F mil is issued,I shall not employ any person in any manner so as to
O b nc subject to the Workers'C.up-a,Iran Laws of CAlirma.'
W - -Ume Applicant ALTER OR ADD TO MECH. 5.00 BUILDING y�
} N N T CB TO APPLICANT: 11',alter making this Cerf it Teale of fix-
FZ emption,you should become subject to the Workers'Compensation APPLIANCE f 5.00 PLAN CHECK 2
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be desired revoked. AIR HANDLING UNIT(TO 10=0C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0=C.F.M.) 6.00 SEISMIC FEE
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 Pern t is issued ISec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000'B.T.U.) 8.00
Lender's Name-0 /I./r " /�2ldn r� HEATING UNIT 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read t uis appluatron an state that the above VENTILATION FAN (SINGLE) 4.00
® information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating 10 building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize reprewmatNes of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(Wet agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
' Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue a ainst said City in con once of the PERMIT ISSUANCE 10.00
gra - off enol. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
u o -, p lc /Cont ate
INSPECTOR COPY