C 8203 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTI FIC PERMIT NUMBER
k APPLICATION & PEW
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aooREss VCoJ G JJ
IOU. DI BUILDING -ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S
NAMEPLAN CHECK VALIDATION
O•' m�v O CITY. ELECTRIC PERMIT FEE! 1 PHON
7,0
CONTRACTORAA 's aPNl/oiL. ► UTLETS-SWITCHES•RECEP 10.00/1.00
JW/AJ It 11C.No,Zh7lZl LIGHTING FIXTURES 10.00/1.00
n��.o/or�IAeQss�TGRS���Ab�'f r PPLIANCES-RESIDENTIAL 4.00
•7�/O /tyl'LHA}3GNE 47,4147Z72, PANELS 10.00 DATE OF APPLICATION
ORRCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENO SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP FrEMP.METER OR POLE INS, 20.00
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
WOO LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a u u I hereby affirm that 1 am licensed under provisions of Chapter 9 A ISSUANCE DATE
y 4 N (commencing with Section 7000)of Division 3 Of the Business and B G. ELECT. PLG. MECH.
v z Professions Co �nJ license is in full fnrcr}I ipp�/
Z o - License Class Lie.Number_ !/ ❑ ❑
o y r¢ Datc-3--77=9Contmct ,�,,yf �$ or
Q Ic¢ OWNER-BUILDER DECLARATION BUILDING PERMIT
0 w u INFORMATION
X g a- N I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
w VALUATION $/FT.
Fw0J Law for the following reason.(Sec.7031.5,Business Professions PERMIT ISSUANCE 10.00
Ew0 Code:Any city or county which requires a permit to construct,alter,
x ¢O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
aa D, requires the applicant for such permit to file a signed statement that TOTAL PESMIT TO
K
$ he is licensed pursuant to the provisions of the Contractor's License ills/ (2 L,1/T TO �i/
R z a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe V vow
f i O Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ 1-0 the basisforthe alleged exemption.Any violation ofSectien 7031.5 STORIES„ TYPE CONSTR.
a3 by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN (EA.) 5.00
of not more than five hundred dollars(4500).): .
❑ 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 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 TOTAL ACREAGE
himself re through his own employees,provided that such improve.
hients mself a throuot gh
or employeeffered for sale.Iided(hat such
building GAS-EA.SYSTEM-1INC.4OUTLETS 8.00
or improvement is Sold within one year of Completion,the owner. GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND c0 Pe Omer
❑ 1,as owner of the property,am exclusively contracting with El !' ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 AS5ESSytJfVQWCkL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves(hereon.and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITAR V$TORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,R.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconsent to self-insure, ZONING ENG.SITE NO..
or a ce IOcate of W rke s'CGmpens o Insumn" or a certified
copy
P°Iicy Na. ��C ifipaRy.) , N
O ❑ Certifie Gpy uh nishe FIRE SPRINK ENERGY T24
C)
cerci ,fP�v Is fi d Wi ' s 1910"' MISC.- REFER TO ORD.
Z
Z0 ApIdicant/C�G Y ❑ N❑ Y ❑ N❑
T CERTIFICA'f1. E EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTH. LIC.NO. PLG.
C• 0 ('This section need not be completed if the permit is for one TOTAL Y E] N❑ V C3 N❑
0 Z hundred dollars(EI00)or less.)
U 0 1'certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL I- mit is issued,I shall not employ any person in any manner So as to
O 0become subject to the Workers'Compensation Laws of California.
a Date-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING 81
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
emption,you shouN become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK ��
provisions of the Labor Code, you must forthwith comply with FEE
C� such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10f.1000.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.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 permit is issued(Sec. MICROFILM
3097,CDC.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Address Addre
Lender's HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that I 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 PLUMBING
ordinances and state laws relating to building construction, and BOILER-CORM I3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) even 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 accrue against saidpity in consequence of(he PERMIT ISSUANCE 10.00
gr in g of
rail MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL ��3rs9
'ignatur Applicant/Contractor Dale
OFFICE COPY