8284 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT-IDENTIFICATION APPLICATION & PERMIT PERMIT NUMBER
BUILDING A A
ADDRESS OT BUILDING-ELECTRICAL-PLUMBING -MECHANICAL uu uu
OWNER'S PLAN CHECK VALIDATION
NAMEp,,,6L1'c'NO Ti:�N-'n(@X n¢R QTY. ELECTRIC PERMIT FEE
• r p
comm Acro PHONE
UTLETS-SWITCHES-RECEP 10.00/1.00
NAME ^-
LIGHTING FIXTURES 10.00/1.00 // , =
roNTRAcroR's APPLIANCES
-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 EOF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLANV
HECK FEE P.C.NO,
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARENG
ADDRESS
OF ar $, Spq-�bP S�MYKfe SPECIAL CIRCUIT 5.00 L- PER9S'y�pN
ZIP EMP. METER OR POLE INS. 20.00 JUL - 155
APPLICANTS MOTORS SEE FEE SCH. t:
ADDRESS /.30/ 5, /1�f RtL'/
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City of Cupertino
< i>. I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
H G w (commencing with Section 7000)of Division 3 of the Business an BL ELECT. PLG. MECH.
F m z Professions Code,and my license is in full force and effect ❑ El El
License Class Lie Number
m - D Date Contractor
m BUILDING PERMIT
Q 0 LL a OWNER-BUILDER DIiCLARA'fION INFORMATION
E OAU MISC.- REFER TO ORD
w s_ n a I hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
F 1. o J Law for the following reason.(Sec.703 L5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which req uires a permit toconstruct,alter,
Q Q improve,demolish,or repair any structure,prior 10 its issuance,also ELEC.CONTR. LIG N0. ELEC.
- DLL requires the applicant for such permit to file A signed statement that TOTAL PE TO
ww a he is licensed pursuant to the provisions of the Contractor's License
As
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Prnl'cssions Code)or that he isesempt therefrom and QTY. PLUMBING PERMIT FEE OA 1A11 c, - 12 11kij
EE O the basis for the alleged exemption.Any violation of Section 7031.5 T R Tv S R
by any applicant for a permit subjects the applicant toanvil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500).):
rK
❑ 1,as Owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 Oc .GROUP RES.UNITS
their sole compensation,will do the work,and the s income 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 upply to an owner of
property who builds or improves thereon,and who does such work F IXTURES-PER TRAP 5.00 SQ. T.FL off AREA TOTALvAChEAGE
e himself or through his own employees,provided that such Improve.
mems are not intended or offered for sale If,however,the budding GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 ING USE
builder will have the burden of proving that lie(lid not build or no
pr'vef purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RE IND CON PB Omer
s owner of the property,am exclusively contracting with El ❑ 1:1 1-1tic• d contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO,
a mfessions Code:The Contractors Liansc Law doe not apply
to on owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a conlruct.00 licensed pursuant to
the Contracor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner 1etc)- WATER SYSTEM 5.00 ALL.vl,TACC.FILE NO.
SC h1P: O. fCLnIM+F N WATER TREATING EQUIP. 5.00
I herchy affirm that I have a certificate of consent to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.3800,Lab C.).
Policy No. Company
O ❑ 9 FIRE SPRINK ENERGY T24
Z_ Z ❑ Certified copy is Bled with the city inspection division. MISC.- REFER TO ORD.
0 Applicant Y ❑ N❑ v ❑ N❑
Hy PERMIT ISSUANCE 10.00
cc CERTIFICATE 01'EXEMPTION FROM WORKERS' FLOOD ZONE A.L.u.c.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. v❑, 'N❑ v ❑ N❑
D. Z t chis section need not be completed if the permit is for one TOTAL
hundred tlollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
EL 1- mit is issued,I shall not employ any person in any manner.so as to
Ow be rte subject to tine Workers'Compensation Laws of California.
Q. Dat Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} UO ,LNOFICI; 'f0 APPLICAN'"E: If,after making this Certificate of ExLot
-
F- Z emption,you should becoue subject to the Workers'Cnmpcnsatiun APPLIANCE 5.00 PLAN CHECK
provisions of lila Labor Code, you must fOr111W1111 comply with FEE
U Such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10JMC.F.M.) 4.00
CONSTRUCT ION LENDING AGI?NCy AIRHANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE AA
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of tine work for which this permit is issued(Sec.
3097,Civ.C.). s AP/.�os A HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lcndin Ndd,.17 ^ter QJ=-.+lLl HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50
Lender's Addrs �@.Sy 3a.54z_ f Ar-,v,- 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 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 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep hmrnluc the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way acme against said ity consequence of the
gr ing of this permit / MECH.CONT. LIC.NO. MECH.
F'ICr_ OTAL TOTAL
n •pli nl/ nGa r [e
INSPECTOR COPY