8259 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
A...ESs o 8259
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
r
OWNER'S
NAME [f�c PLAN CHECK VALIDATION
�TIJ /�/Ix U QTY. ELECTRIC PERMIT FEE
1� PNONE N I� 1
NDMERAGTORs UTLETS-SWITCHES-RECEP.' 10.00/1.00
\- l7 LIc.N LIGHTING FIXTURES 10.00/1.00
CONTRACTOR
ADDRESS
' n 1--1 S--r, PPLIANCES-RESIDENTIAL 4.00
COof
SO PRO. PANELS - ` 10.00 DATE OF APPLICATION
OR
PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
RR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP ITEMP.METER OR POLE INS. 20.00
APPLICANT'S MOTORS SEE FEE SCH.
Abort E55
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DOE CLARATION TEMP.POLE 30.00
a U w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
vHi (commencing with Section 7000)of Division 3 of the Business and
¢H BLDG. ELECT. PLG. MECH.
F y z Professions Co cense is in full 0
z o m Licen la Lia Numb
F w Dale Contractor
`a Ow
PERMIT
rc
a OWNER-BUILDER DECLARATIU
o s O INFORMATION
w ;U.y I hereby affirm that I am exempt from the Comractor's License MISC.- REFER TO ORD
.. 0 st Law for the following reason.(Sec.7031.5,Businessland Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
Code:Any city orcounty which requires a permit to construct,alter,
¢ Q Q improve,demolish,or repair any structure,prior toils issuance,also ELEC.CONTR. LIC.NO. ELEC.
O¢ requires the applicant for such permit to file a signed statement that TOTAL pERMIT O
n w w" he is licensed pursuant to the provisions of the Contractor's License
F z i Low(Chapter9(commencing with Section 7000)of Division 3 of the
¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢r$ the basis for the alleged exemption.Any violation t to action en L$ STORIES TYPE CONSTR.
T ; by any applicant for apermit subjects $5000.licamloucivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($5001.):
❑ 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 ale(Sec. 7044, hosiers, and Prul'cssions DRAINS-FLOOR,ROOF,AR EA,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 F IXTUR ES-PER TRAP 5.00 SQ.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such ice building
hients mself a not through des oroffered for employee sale,provided
ed that s the building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
Or improvement is sold within one year of completion*
the owner. GAS-EASYSTEM-OVER 4 (EA.) 200 BUILDING USE
builder will have the burden of proving that he did not build or ice- GAS . .
- RES IND CON PB Other
0 (2
move for purpose III ale.). 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 ASSESSORSPARCEL NO.
and Professions Code:The 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 contractors)licensed PLOCranl to
Elie Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
0 lam exempt under Sec ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPI?NSA'IION DECLARATION WATER TREATING EQUIP. 5.00
I hereby al Drm that I have a certificate ofconsent to self-insure,
or a certificate of Workers'Compensation his. ace,or a certified ZONING ENG.SITE NO.
copy t h�erj�Syy�4fy�,.�.� y)
I'olicY l®Ii7l.tpy is heDa�I Y
Q Ve rlilicd copy is hcrcbyf rnishcd. FIRE SEE INK ENERGY TQA
Z 2 Certl f i. inspection di n.
O Applicant �'IYi�1-r MISC- REFER TO ORD. v ❑ N v ❑ N❑
0: rA CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
L COMPENSATION INSURANC17 PLG.CONTR. LIC.NO. PLC. Y[:] N❑ Y C] N❑
CL Z (This section need not be completed if the permit is for one TOTAL
hundred dollars(5100)of less.)
U O 1 certify that in the perlinmance of the work for which this per, OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any manner so as to
O W become subject to tiie WorkerCompensation Laws of California.
Date n licant BUILDING
a pP ALTER OR ADD TO MECH. 5.00
} W NOTICE TO APPLICANT: If,after making this Certificate of Es.
F Z_ emption,you should become subject to tire 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 10000.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the c.of the work for which this permit is issued(Sec HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I 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 refiling In building construction, and BOILER-COMPI3 H.P.or 100,000 B.T.U.) 6.00
hereby authorise representatives of this city to enter upon the BOI LER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree 10 ,are, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANC �� 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
gran' fthis a It (� MECH.CONT. LIC.NO. MECH. '
04 / 5 1 N ' I y� ^1 TOTAL I 00 TOTAL
S' re of Applicant/Contractor U e V ( f EL.1-Lnnur Vs
OFFICE COPY