8163 APPLICANT TO FILL IN INFORMATION WITHIN'REDI` LINES -,USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON - / PERMITNUMBER
BUILDING APPLICATION & PERMIT f
Wil"• AOOREss BUILDING-ELECTRICAL-PLUMBING -MECHANICAL 13
OwNEP'S , PLAN CHECK VALIDATION
"AME
Sfoe/C'/mrd// f. CITY. ELECTRIC PERMIT FEE
PHONE
738 3�.Sg
CONT TORS / OUTLETS-`SWITCHES-RECEP 10.00/1.00
.z
Lot.NO. LIGHTING FIXTURES 10.00/1.00
. ,
ADDRESSAPPLIANCES'-RESIDENTIAL 4.00
1Ai vHONE _PANELS `� 10.00 DATE OF APPLICATION
a, ARCHITECTPLAN CHECK FEE P.C.NO.
{
OR
Zu.nny L PANELS-(OVER DAMP) 20.00
uc.NO. ' SIGNS TRANS. 3.00
r
\A40
RCK On
ENG. SPECIALCIRCUIT 5,00 PERMIT VALIDATION
I L2 IP 7 EMP.METER OR POLE INS. 20.00
t APD.ESSPLICANTS MOTORS SEE FEE SCH. rte
ADDRESS \VyI(fj'y'T-
}? SERVICE CHANGE 20.00
¢ / TEMP.POLE 30.00
Foo ) LICENSED CONTRACTORS DECLARAf1ON
Q
u v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
I z "' Itcontmencing with Section 7000)of Division 3 of the Business and
Q n '13 BLDG. ELECT. PLG. MECH.
F D z Professions Code,and my license is in full force and effect.
i m W License Class Tic.Number
o
Dale Contractor
a x f BUILDING PERMIT
or OWNER-BUILDER DECLARATION
do e' MISC.- REFER TO ORD INFORMATION
wLL t- 1 hereby affirm that 1 am exempt from the Contractor's license
.. OJ Law for the following reason.(Sec.7031.5.Business and Professions pERM1T ISSUANCE 10.00 VALUATION SIFT.
� - 0 Code:Any cilyor county which requires a permit to construct,alter,
rtR Q 2O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
n wo ¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
es u he is licensed pursuant to the provisions of the Contractor's LICmw
F z i Law(Chapter 9(conrmencing with Section 7000)of Division 3 fthe ,f ,tiJ(Xj S/ .TT�uG%V
Q Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
M i o
¢ F o the basis for the alleged exemption.Any violation ofSection 7031.5 STORIES TYPE CONSTR.
a ; m by any applicant for apv,mit subjectsthe applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500f):
❑ I,as owner of the property.or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 oeC.GROUP RES.UNITS compensation,will do the work.and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 5.00
Code:The Cont motor'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 TOTALACREAGE
himself or through his own employees,provided that such imProve-
A� mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement Is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or um GAS USE
} pmve for purpose of sale.). - INDUSTRIAL WASTE INTER. 30.00 RES IND CON P8 Omer
l ❑ I,as owner of the property.am exclusively contracting with ❑ ❑ ❑ ❑ ❑
(•1 licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code: Me Contractor'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
i contracts for such projects with a contractur(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ Iamexemptunder Sec. ,B.&P.C.fill this WATER HEATER W/VENT , 6.00
milsml
Owner "'�
117M WATER SYSTEM 5.00 V
yy��� �� l,,pQerq ACC.GATE ACC.FILE NO.
• w' 7R R SCO 1PISNSnfION bEZ`LA RnTION WATER TREATING EQUIP. 5.00
I hereby affirm Ihnt I have a certificate ofecnsent toself-insure, TONING
m a certificate of Workers'Compensation Insurance,or a certified. ENG.SITE NO.
copy thereof(Sec.3800,I-ab.C.).
Policy No. Company
'0 ❑ Certified copy is hereby furnished.. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is Ned with the city inspection divisign.
HO e MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
Applicant I Y N V N
Cc LQ CERT IFICA'fG OI'IiXIiMPf10N7�4 �I' )It1.1iHS' ` PERMIT ISSUANCE 10.00 PtOODzoNE A.L.u.C.
LU > COMPENSATION INSURANCE PLG.CONTH. LIC.No. PLG. YE] N❑ [:] N❑
Z (This section need not he completed if the permit is for one TOTAL
hundred dollars IS f 00)or less.)
U O I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
Ow become subject to the Workers'Compensation Laws ofCalifornia.
o- Date Applicant - ALTER OR ADD TO MECH. 5.00 BUILDING 17 JU
} N NOTICE TO APPLICANT: It,after making this Certificate of Ex- �-
F 2 emption,you should 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 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE �v
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 permit is issued(Sec. MICROFILM
3097.Civ.C.). i D HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address �la HEATING UNIT(OVER 100,0008.T.U.)9.50 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 BOILER- H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to huddling construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000BTUI SEE FEESCH. MECHANICAL '
above-mentioned property for inspection purposes
(we) 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 accme against said City in consequence of the PERMIT ISSUANCE 10.00
gmnto ofthispennit MECH.C.NT. LIC.NO. MECH.
yE �Gf�,�� /�IGt TOTAL TOTAL
'�� SagdrNre of A pli am/Cmrtruc{or c/
INSPECTOR COPY
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