8218 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
i RMIT NUMBER
Ja oft I LDING PROJECT IDENTIFICATI40
UILDING APPLICATION 8l PER
ADDRESS `oJ G I yU`
• '� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
WNER'S
PLAN CHECK VALIDATION
AME OTY. ELECTRIC PERMIT FEE
• ( PNONE ^�
CONTRACTOR OUTLETS-SWITCHES-RECEP 10.00/1.00
.
LIC.NO, p ILIGHTING FIXTURES 10.00/1.00
CONTRAC
TOR's
ADDRESSDRESSPPLIANCES-RESIDENTIAL 4.00
A
D PHONE PANELS 10.00 DATE OF APPLICATION
OR
ARCHITECT PANELS (OVER 200 AMP), 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDREOR SS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ADDRESS AMOTORS SEE FEE SCH.
ORSERVICE CHANGE 20.00 9/4;
F0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a Uz u 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
H rt Ii (commencing with Section 7000)of Division 3 aoDfd t�hfe Business and ELECT. PLG. MECH.
F N z Professions CoQs•,,and my license is in full totes 55��O ❑ ❑ ❑
oz m W Licen Class-1}_1_Lie.Number 7 55
T H Dote Contractor A
a x s , API r-2 B NG PERMIT
5 M w a OWNER-BUILDER DECLARATION 9 RMATION
w 0 'r 1 hereby affirm that I am exempt from the Contractor's License
MISC.- REFER TO ORD
w VALUATION SIFT.
H LL o j Law Code: ny cilylowingrey which
quires a permit tocnd Professions PERMIT ISSUANCE 10.00
w j Code:Any mulish cor n pair any structure permit o its issuance,
also alter, „
Li ¢a p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. Q '
Li 0 a. requires the applicant for such permit to file a signed statement that TOTAL PERMIT TQ
w m m he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter and
Professions
C de)or Section is exempt therefrom and
a he
Business and Professions Code)or that he is exempt therefrom and QTY. ' PLUMBING PERMIT FEE
¢ r$ the basis for the alleged exemption.Any applicant
otoa cion malty $TORE ES TYPE CONSTR. -
n; � by any applicant fora permit subjects lheapplicant toa<ivilpenalry ALTER-DRAIN&VENT-WATER IEA.) 5.00
of nor mom than five hundred dollars(8500).1.
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and ProfessionsDRAINS-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
. Repts.,amself not hrough
ownemployees,for
provided I ,however,the
improve- GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
mems are not intended or offered ee sale.If,however,the building
or improvement is sold within one year of completion,the owner. GAS-EASYSTEM-OVER 4 IEA) 200 BUILDING USE
builder will have the burden of proving that h . . .
e did not build or am. R IND ON
PB "barprove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the Project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 A$$ES$ORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts forsuch projects with a contmctons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sac..,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dale WATER SYSTEM 5.00
ALC.DATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificale of consent to self-insure, TONING
�/� or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
,P6 copy thereof(Sec.3800,Lab.C.).
Policy Dl WA_IA Company L+4 qy
Q ❑ Certified copy is hereby furnished. FIRE SPR INK ENERGY T 24
Z
Z ❑ Certified copy is Bled with the city inspection division. MISC.- REFER TO ORD.
F O Applicant-
CC
N❑ V ❑ N❑
va PERMIT ISSUANCE 10.00 FLOOOZONE A.L.U.C.
W - CERTIFICATE ENSATI EXEMPTION FROM WORKERS'
W �_ COMPENSATION INSURANCE PLG.CONTR. LIQ NO. PLG.
O This section need not be completed if the permit is for one TOTAL Y❑ N❑ V❑ N❑
Z hundred dollars(E 100)or less.)
L) O 1 certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL 1- mit is issued,1 shall not employ any person in any manner so as to
U become subject to the Workers'Compensalion Laws of California. BUILDING
' F
i Date Applicant ALTER OR ADD TO MECH. 5.00
} N NOTICE TO APPLICANT: If after making this Certificate of Ex
? emption,you should become subject to the Workeri Compensalion 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 ITO IO,MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
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(See. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 6.00
Lender's Name
Lender's Address HEATI NG UNIT[OV ER 100,000 B.T.U.)9.50 ELECTRIC
I certify that 1 have read this application and state(hat the above VENTILATION FAN (SINGLE) 4.00
• information is correct.1 agree to comply with all city and countyPLUMBING
di
ornances aad state laws relating to building construction, 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(Over 700,000 STU)SEE FEE SCH. 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 accrue against said City in consequence of the PERMIT ISSUANCE 10.00
grant f this permit MECH.CONT. LIC.NO. MECH.
�1 TOTAL TOTAL
Signature of Applicant/Contractor Dare
OFFICE COPY
��' 012'