8203 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS /j'�(n�f{'�
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL0!0 L32'L.7 L1
OWry R' - PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
�� PHON
NAMEpAcioRs OUTLETS-SWITCHES-RECEP 10.00I1.00
Su��itioz Auro -
G uc,No. LIGHTING FIXTURES 10.00/1.00
ADDRFicroas9sv35 APPLIANCES-RESIDENTIAL 4.00
ADDRESS
Q C�. N NE ' PANELS 10.00 DATE OF APPLICATION
ORGeoecr PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.No.
ENGINEER
LIC.NO SIGNS TRANS. 3.00
AARC
DDRESS ENG. SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLI MOTORS SEE FEE SCH.
ADDRDDRESSSS
SERVICE CHANGE 20.00
-, 02 LICENSIi1)CON'IRAC'I'ORS DECLARATION TEMP.POLE ,Kf 30.00
G o ca I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w a (commencing with Section 7000)of Division 3 of the Business and
Q B G. ELECT. PLG. ` MECH.
Es z Professions Code and my license is in full for
0 �'
❑ ❑ ❑
2 o y - License Class _-_� Lic.Number rL
O m -� Deli Contractor
¢ m f -a BUILDING PERMIT
rc o SE SE U OWNER-BUILDER DECLARATION INFORMATION
v, I- 1 hereby affivn that I am exempt from the Contractor's License MISC.- REFER TO ORD
i u ,� y P VALUATION $/FT.
HUO J Law for the following reason.fSec.703 L5,13usinessand Professions PERMIT ISSUANCE 10.00
Code Any city or county which requires a perm,(to construct,alter,
SEae ¢o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO ELEC.
- O, requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w m he-is licensed pursuant to the provisions of the Contractor's License
H z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
- A Business and Professions Code)or that lie is exempt therefrom and OTY. PLUMBING PERMIT FEE
-,¢ r ca the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR,
eL 2? by any applicant for a permit subjects the applicant toacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
5frot more than five hundred dollars(8500).)'.
❑ 'Ipusrsowner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
the .sole compensation,'will do the work,and the structure is not OCC.GROUP RES UNITS
intended-oirofDRnTfor sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Con Hfrcmr:x Licanse Law does not apply to an owner of s
` property who builds or improves thereon,and who does such work FIXTURES-PER TRAP " 5.00 SO.FT:FLOOR AREA TOTAL ACREAGE
. .,mattf,, through atintended
or offered for
If,provided improve- GAS-,EA.SYSTEM-1 6.00
menus are not intended or offered for salt.If,however,the building
or improvement will
is sold burden
within one year of completion,the owner- GAS-IEA.SYSTEM-.OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or ire- BUILDING USE
prove for owner of sale.). INDUSTRIAL WASTE INTER. 30.00 REs Ino CON PB Omer
❑ d as owner OI the property,he exclusively contracting with ❑ ❑ tA ❑ ❑
licensed contractors kI construct the project(Sec,7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 gsSEssoR A CEL NO.
and Professions Code:The Contractor's License Law does Hot apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS OVER 5(EA.) 1.00 -
conlmcts for such projects with B contractors)licensed pursuant to
the Cnntmcmr's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ l um exempt under Sec, ,B.&P.C.for this WATER HEATER W/VENT 6.00
rection
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hemby ufNrm that I have a certificate of consent to set Finsure, ZONING ENG.SITE NO.
or a certificate of Workers'Conifers. ' n Insurance,Or a certified
copy�9(JaFjfcJ3B0�lPaIyJ.). /%CL' G
colic pawe
O ❑ Certified copy is her furnished FIRESPRINK ENERGYT-24
z Z ❑ Cedificd7'ntly is tl with tl��rp insoabtlon ivision.
O Applicaol�L/�d .J/(�[� A/ MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ IN
� N
chRrIFICATI10EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTH. LIC.NO. PLG, Y❑ N❑ v❑ N❑
0 0 CI' his section need not be completed if the permit is for one TOTAL
hundred dollars(S 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued, I shall not employ any person in any manner so as to
Ow become subject to the Workers'Compensation Laws of California_
CL Date Applicant ALTER OR ADD TO MECH. 5.00 -BUILDING Q
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
�.. Z cmption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 FEE r J
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0)000OF.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency lot EXHAUST HOOD (WITH DUCT) 5.00
the 3097, MICROFILM
Civ.C.�nce of the work for which this permit is issued(See. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Linder', HEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Name
Liamm', s
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all cty and county PLUMBING
ordinances and state laws relining to building construction, and BOILER-COMP(3 H.P.or 100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP IOVB!(00,000 BTU)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 PERMIT ISSUANCE 10.00 CONST.TAX
may in any wa accrue against said Cily in consequence of[he
gra ing of th p mit. - MECH.CONT. LIC.NO. MECH.
' -p Torg` TOTAL
I tar PP Icanl ra
ntctor Dale //3rJ 9
INSPECTOR COPY