8161 APPLICANT TO FILL 0V'INFORMATION'WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING - APPLICATION & PERMIT
7 aoDREss
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NG-ELECTRICAL-PLUMBING-MECHANICAL8161
WN RS PLAN CHECK VALIDATION
NAME
- OT.V`. ELECTRIC PERMIT FEE
T vHorvE
NAAMERacrons UTLETS-SWITCHES-RECEP 10.00/1.00 fy
uc.No. LIGHTING FIXTURES 10.00/1.00 - y
r CONTRACTOR'S
ADDRESS PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION 4
ARCHITECT PLAN CHM77 P.C.NO.
on PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
l ADDRESS ENG SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT'S
ADDRESSF MOTORS SEE FEE SCH. /
t SERVICE CHANGE 20.00 '
F
00 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a u 1 hereby affirm that 1 am licensed under provisions of Chapter 9
2 w ISSUANCE DATE
(commencing wish Section 7000)of Division 3 ol'the Business and
so G A BLDG. ELECT. PIG. MECH.
y i 1'anfessions
of.and my license is in full force and effect-
• o0 u,w License Class Lic.Number
m F Date Contractor
X S, w a OWNER-BUILDER DECLARATION
BUILDING PERMIT
D MISC.- REFER TO ORD INFORMATION
w g LL y 1 hereby affirm that I am exempt from the Contractor's License
H ¢ Oj Law for the following reason.ISec.7031.5,Businessland Professions PERMIT ISSUANCE VALUATION $/FT.
Code:Any city or county which requiresa permit toconstiod,alter, t
' 2RQ0
improve,demolish,Or repair any'structure.prior tO its issuance.also ELEC.CONTIT LIC-NO. ELEC.
- D¢ requires the applicant for such permit to file a signed statement that TOTAL
w$a.w he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
io Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE 4� 4C 7,
¢ f m the basis for life alleged exemption.Any violation of Section 703 L5 STORIES TYPE CONSTR.
d3 _ by any applicant fora permit suhjects the applicant macivil penally ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(S500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole cDlmpensaton,will do the work,and the structure is not OCG GROUP RES.UNITS
intended or offered for sale(Sec. 7044, Business and ProNssion( DRAINS-FLOOR,ROOF,AR EA,CON D. 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 50.FT,vLoon AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
memsarenotintendedoroffinedforsale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner-
, builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of sale.). RES INDUSTRIAL WASTE INTER. 30.00 IN Other
❑ as owner of the property,am exclusively contracting with
licensed contractorsconstructtproject(Sec. 7044,Business LAWN SPR INKLERS- 1 INC5 00 13 El
❑ El 1:1
ASSESSORS PARCEL NO.
and Professions Colic::TThe Con bmmsr 9 License Law does not apply V.B.. .
to;in owner of properly who builds of improvncensedthereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contrtracto Hs)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT No. PARCEL No.
❑ I um exempt under Sea ,B.&P.C.for this
reason WATER HEATER W/VENT 6.00
' \i
/\ Owner IJateA�,� WATER SYSTEM 5.00 ACC.DATE ACC.FILENO.
WORK ERS'CI)h1P oN AT10 DECLARATION;'. WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofconwnt tcTi lGinsurc,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG,SITE NO. -
71 copy thereof ISec.3800,Lab.C.l. _
�t
Policy No. Cn mpany
'I] ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T-24 `.
'Z Z 0 Certified copy is filed with the city inspection division.
FO Applicant MISC.- REFER TO ORD. YE] No Y ❑ NE]
CC h CI!RTII'ICA'I'I:OI'EXi'MPTION I'ROSI WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE AL.U.c.
LU > COIIPEN$ATIONINSURANCIi PLG.CONTR. LIC.NO. PLG.
O I'Fill, section need not be completed if the permit is for ons TOTAL V N Y ❑ N EJ
Z hundred dollar,IS 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 I- mit is issued.I shall not employ any person in any manner so as m
U W Leconte subject to the Worker\Compensation Laws of California.
Q. Dale Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate off-Ex-
'F ? emption,you should become subject to the Workers'Compensation App LIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you (mast forthwith comply with FEE
.U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10=GF.M.) 4.00
CONSTRUCTION LFNDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
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,Cis,C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address H EATI NG UNIT IOVER 100,000 B.T.U.)9.50 ELECTRIC 'a dl"0 '
I cenify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4,00
information is correct I agree to contPly with all city and county PLUMBING
ordinances and slate laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6-00
hereby authorise representatives forms of this city to enter upon the BOILER-COMP f0ver 100,000BTU1 SEE FEE SCH. MECHANICAL
above-mentioned property tativsp of
purposes.
(We) agree to sous, indemnity and keep barodess tin City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may i y way accrue against said 'ty in consequence of the
Plan this erm'L MECH.CONT. LIC.NO. MECH.
\ ' TOTAL - TOTAL
y
igefature of Appl' m abntractor Date
INSPECTOR COPY
I