8142 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDBUILDING PROJECT lDENTIFICATION PERMIT NUMBER
APPLICATION & PERMIT
AOOREss
S BUILDING - ELECTRICAL-PLUMBING-MECHANICAL /^�{�l U
OWNER'S PLAN CHECK VALIDATION
NAME - CITY. ELECTRIC PERMIT FEE �/
PHONE ♦ 6O /? /`6 6/cfS
NAMEHAcroRs OUTLETS-SWITCHES-RECEP 10.00/1.00
7-5333
L.C.N.. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
AOOR EBB
PHONE PANELS 10.00 DATE OF APPLICATION
on
nCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIc.rvO. SIGNS TRANS. 3.00
ADDRESS sea SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 20.00
APPLICANT s MOTORS SEE FEE SCR.
ADDRESS
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 QIP O)
Q =u I Jmreby'affirm that I am licensed colder provisions of Chapter 9 I �q ISSUANCE DATE
H a n (commencing with Section 7000)of Division 3 of the Business and r BLDG. ELECT. PLG. MECH.
H N z Professions Code,and my license is in full force and effect. -7 L- x
/�,C(h ❑ ❑ El [715. 0 m -/ License Class Lie Nwnber
o m F w' Date Contractor
- E < �R BUILDING PERMIT
¢ m ¢ a 01 FR-BUILDER DECD$
o a MISC.- REFER TO ORD INFORMATION
3 u_ y 1 hereby affirm that I um exempt from the Sontractor
'L Lice a VALUATION $/FT.
u_ 0 a Law for the following reason.(Sec.]031.5.Business and Professions PERMIT ISSUANCE 1 ��
Code:Any city or county which requires a permit In construct,alter,
¢ ¢ ¢ o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIB.NO. ELEC. �y
e wP¢ requires the applicant for such permit to file a signed statement that TOTAL.d GlY/L PERMIT TO
m" he is licensed pursuant to the provisions of the Contractor's License
FiQ
Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthc `a .Sib/'Y�`>iei/� UL.
E 0 Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of$eetion 7031.$ STORIES TYPE CONSTR.
n ;,m by any applicant for it permit subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.) 5.00
of not..hone than five hundmd dollars($500).):
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 4.00 DCC.GROUP RES.UNITS
their sole compensation,will do the work,and the soucture 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 docs such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees.Provided that such improve-
/ ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 1 NC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA,) A 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
CII,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 ASSESSORS PARCEL N0.
and Professions Code The Contractor's License Luw docs not apply
to an owner of property who builds or improves thereon.and who LAWN SPR INKLERS-OVER 5 (EA.) 1.00 a
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200th/10.00
the Contractors License Law. TRACT NO. PARCELNO.
❑ 1 am 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.
WORK ERS'COMPENSA'f10N DECLARATION WATER TREATING EQUIP. 5.00
I hereby 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.
co Py thcreof(Scc.
Policy No. Company s 1/1h.M'RI A1.10
0 ❑ Certified copy is hereby fh rni hh� .� FIRE SPRINK ENERGY T-24
Z 2 Certifie - J 'h the city inspection division. MISE- REFER TO ORD.
Q ,( Aflpllcant Y ❑ N❑ Y ❑ N❑
W 1 COMPENSAT IONI SURANCI; PLG.CONER MIT ISSUANCE IC.NO. PLG.
� - Cli T'IFIG\'I'Ii CIF 4SXIiMI'1'1 PROMWORKERS' UID.. - FLOOD ZONE A.L.U.C.
W > COIAPENSAI[ON 141URANCI: PLG.CONTCL Zdr
(This section need not be completed if the permit is for one TOTAL p? �- Y E] N❑ Y E3N❑
huned dollars(51001 'less,)
U O 1 certify that in the perfurmance of the work For which this per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY
W F mit is issued,1 shall not employ any person in any manner so as to
Ow beanie subject to the Workers'Conhpansation Laws of California.
0.W Dam Applicant ALTER OR ADD TO MECH. 5.00 BUILDING ya f
} to N'01'ICE TO APPLICANT: If,after making this Certificate of Ex-
F 2 carnation,you should become subject to the Workers'Compensal ion 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 10MOC.F.M.) 4.00
CONSTRUCTION LENDINGAGENCYAIR HANDLING UNIT ROVER 10PIMC.F.M.) 6.00 is SEISMIC FEE �r1
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(Sec. MICROFILM
3097,Civ.CJ, HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
% Lenders Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
or t
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 anJ county' PLUMBING _9
ordinances and state laws relating to.building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 �l
hereby authorise representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes. !n
(We) agree to save, indemnify and keep haraless the City of MISC.- REFER TO ORD. i
Cupertino against liabilities,judgments, costs and expenses whichpERMIT ISSUANCE 1 QCONST.TAX
may in any way accrue again t mid City in consequence of the
SihgAimoiLt/Conlrac or MECH.CONT. LIC.N0. MECH. `
TOTAL
GU TOTAL
�3i
� -
INSPECTOR COPY '