8359 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
I'
' BU I LDING PROJECT IDENTIF I CATION PERMIT NUMBER
i.j. a0nDING APPLICATION & PERMIT (('��/�r(�
AOOREss BUILDING -ELECTRICAL-PLUMBING-MECHANICAL TS S'1M
__ 8 V!hull 9
OWNER'S PLAN CHECK VALIDATION
NAME I CITY. ELECTRIC PERMIT FEE
ill / Rn r r PRorvE
CONTRACTOR'S
t NAME t OUTLETS-SWITCHES-RECEP. 10.00/1.00
T LIC.N04¢E107 I LIGHTING FIXTURES 10.00/1.00
CONTRAC70Rs APPLIANCES-RESIDENTIAL 4.00
ADORESS
7 n + FROrvE + I•�7,1I PANELS 10.00 DATE OF APPLICATION
ARC ITEC PLAN CHECK FEE P.C.NO.
OR ` PANELS (OVER 200 AMP) 20.00
ENGINEER
uc.No. SIGNS TRANS. 3.00
not Ess eNc. SPECIAL CIRCUIT 5.0Q PERMIT VALIDATION
9
zip TEMP.METER OR POLE INS. 2(100 S -
APPucANT'S ADDREss MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00a/��
G v y w 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE(commencing with Section 7000)of Division 3 of the Business and
a �, BLDG. ELECT. PLG, MECH.
R w z Professions Code,and my license is in full force and c(18d
z o - License Class �7 / Number
4 m °w Date � i 5. Contmetor
� ' �.-• BUILDING PERMIT
a OWNER-BUILDER DECLARATION
E o a uINFORMATION
w 3 LL H I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
F u 0 J Law for the following reason IScc.703 1.5,Businessand Prom sionsPERMIT ISSUANCE t(.(0 VALUATION $/FT.
es
Code:Any city or county which requira peNn it In construct,alter,
¢ rt ¢ o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. ✓ V ry x/
ea
¢ requires the applicant for such permit to file a signed statement that TOTAL a/ PERMIT TO
w.m" he is licensed pursuant to the provisions of the Contrnemr's License
Law(Chapter 9(commencing with Section 7000)of Division 3 of the '� '/
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE I)C MoGIJ1J
F m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES C5AE-�NSTR
ate _ by any applicant fora permit subjects the applicant to a civil penalty ALTER-DRAIN (EA.) 5.00 'P
of not unto,than five hundred dollarsf8500d): 00 DEV ICE 4 -! _
❑ 1,as owner,of the property,or my employees with wages as . .
their role compensation,will do thre e work,and the structuis not BACK F LOW PROTECTOCG_ la GROUP RES.UNITS
intended or offered for sal,(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,CON D. 5.00
Code:The Contractor's License Lew does not apply to an owner of
properly who builds or improves therron,and who does such work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own Cm ployees,provided that such improve-
ments arc not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or ire- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,as owner of the properly,em exclusively contracting with ❑ ❑ ❑ ❑ 0
licensed contractors to construct the project IScc. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS 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 SPRINKLERS-OVER 5 (EA.) 1.00
contracts for 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 an,exempt under Seer ,B.&P.C.for[[,is , WATER HEATER W/VENT 6.00
reason
Owner Dote WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 `
1 hereby affirm that
or I have a p certificate of consent to or
censure,
o a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy tNo. Soc.38Cm Lab,N.y .
Policy Na C'om Dany A1,15,
❑ Certified copy is hmeby lunushed. /'+ FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is fJed withOte city i pm Gn div'ton✓
O Applicant / >. Tr MISC.- REFER TO ORD. v N Y N
OC h CERTIFICATE 01'EXEMPTION_F?0NiV RKF.RS'__' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
DU > COMPENSATION INSURANCE / PLG.CONTR. LIC.NO. PLG.
CL Z (This section need not be completed if the permit is for one TOTAL V N Y E] N
hundred dollars IS 100)or less.)
U O 1 certify (fiat in the performance of the work for which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
ly U mit is issued.1 shall not employ any person it any manner so as In
become subject to the Workers'Compensation Lows of California.
U1 Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING V
>_ to NOTICE,TO APPLICANT: If,after making this Certificate of Ex-
f" Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shell be deemed revoked. AIR HANDLING UNIT(TO 10PIXIC.F.M.) 4.00
CONSTRUCTION UFNDING AGENCY AIR HANDLING UNIT(OVER 10)000C.F.M.) 6.00 SEISMIC FEE 5�
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.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information n correct 1 agree to comply with n ail city and count PLUMBING
ordinances and state laws relating to building conslmetum, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over100,000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree In in modify and gcep'liormless the City of MISC.- REFER TO ORD.
Cupertino again /Itabili ' s,judgme tf cnaLv/at expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any ay ace a against City�m onsequence of the
granting of Isis pent MECH.CONT. LIC.NO. MECH.
S/ TOTAL
Signature of Ap TOTAL
Leant/Contractor Dale 7A
INSPECTOR COPY
1