8259 (3) ;APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
aNLDiNGAPPLICATION & PERMIT ����
AOOREss 29
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'$
NAME �� PLAN CHECK VALIDATION
Nis- fU i, _ QTY. ELECTRIC PERMIT FEE
P
NANEA"..
UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.ND LIGHTING FIXTURES 10.00/1.00
ACONTRACTOR n sL S� P LI ANCES-RESIDENTIAL 4.00
DDRESS tSJ 'r1 T
�� PRONE PANELS 10.00 GATE OF APPLICATION
oR T PANELS (OVER 200 AMP) 20.00 PLANCHECKFEE P,O.NO. /ly
ENGINEER' _ YJ
LIC,NO. SIGNS TRANS. 3.00 I
ARCH,
oo eSENG' SPECIAL CIRCUIT 5,00 1 PERMIT VALIDATION
zip TEMP. METER OR POLE INS. •20.00 - _-
APPLICANT MOTORS SEE FEE SCH. D
AOORE$$ �\
SERVICE CHANGE 20.00
° ¢ TEMP.POLE 30.00 7 �4/�(f
r o o LICENSED CONTRACTORS DECLARATION
aU w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
H rt y (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H z P"Alssions CodJ and n scene is i"fu It fo yml of 1:ct
+'z O-w - LicensClass Lie Numb r
12 F o Uatc Contractor
«m El Lq
BUILDING PERMIT
rc w ¢ OWNER-BUILDER DECLARATIOu INFORMATION
w� I hereby efl'irn that I int exempt from the Conirvctor's"Lieensr- - MISC..-.(,t-r. .,:,;.y-- _ ,-REFER ATO ORD - VALUATION $/FT.
�s. .. o j Law for the following reason.(See.7031.5.Businessand Professions
,yH _ PERMIT ISSUANCE ... 10.00
w0 Code:Any city orcounly which requiresa permit toconsDoCt.alter,
ic Q ¢ 0 Improve,demolish,or repair any Structure,prior to Its issuance.also EC.CONTR. LIC.NO. ELEQ
Ou requires till applicant for such permit to file a signed statement that TOTAL PERMIT TO
whe is licensed pursuant to the provisions of the Contractors License
i
Law(Chapter 9(commencing with Section 7000)of Divisiohh 3 ofthe
4io Business and Professions Code)or that he is exempt therefrom and
¢ H a the basis for the alleged exemption.Any violation of Section 7031.5 OTY. PLUMBING PERMIT FEE
5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN&VENT-WATER IEA.) 5.00
of not more than five hundred dollars($500).):
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the sr ructme 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
propeHy wllo builds or improves thereon,and who does such work F IXTUR ES-PER TRAP - 5.00 50.FT.FLOOR AREA TOTAL ACREAGE ,
® himself re through his Own employees,provided that such improve-
mems are not intended or offered for sale.If,however.the building GAS-EA.SYSTEM-1INC.4OUTLETS 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 IEA.) 2.00 BUILDING USE
for RES IND CON PB Other
prove 1,aso nee olf the.). P INDUSTRIAL WASTE IN TER. 30.00
❑ L as owner of the property,he exclusively contorting ins with
licensed contractors: Iie Contrathe project(See. 7044,Business LAWN SPRINKLERS-1 INC5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractus'. improv.Law docs not apply
to contracts
owner of property who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
tiro Cont for s L projects with u contranorts)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA,200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exenhpt under Sec. ,B.&I'.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dale WATERSYSTEM 5.00
��•� ACC.DATE ACC.FILE NO,
W'ORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to sell-insure,
or a certificate of Workers'Compensation Insurance,or a certified 40NING ENG.SITE NO.
I'nlic 1�--
❑ tcrlils hcrebyy(urnlsl-- \ FIRE SPRINK ENERGY T-24
Z Ceni b qY, is NeJ 'R the cly1 i-nspection diviAon. misc.- REFER TO ORD.
O Applicanl� �1}1= ♦ {n t3 _AY N Y N
cN CERTIFICATE OF EXEMPTION FROM WORKERS' *".PPERM IT.ISSUANCEy • a, 10.00 .FLOOD ZONE - A.L.UC.
JU > COWIPFNSATION INSURANCE PLG.CONTH. LIC.NO. PLG.
d f his �
O ( section need not be completed if the permit is for one TOTAL V N Y ry
Z hundred dollar,IS 100)or lcssI
U O 1 certify that in the performance of the work tor which this per- QTY MECHANICAL PERMIT FEE
LL H mit is issued, I shall not employ any person in any manner so as to FEE SUMMARY
U become subject to the Workers'Compensation Laws of California.
O to Date Applicant BUILDING
>_ w NOTICE TO APPLICANT: If,after making this Certificate of be- ALTER OR ADD TO MECH. 5.00
Z_ emption,you should become subject 10 the Worker 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 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a ......traction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's NaHEATING UNIT(OVER 100,000 B.T.U.)Lenders ame
Address ELECTRIC
Icertify that l have read this application and stall that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorise representatives of this city to cater upon the BOILER-COMP;Over(00,000 BTU;SEE FEE SCH. MECHANICAL // Oh7
above-mentioned property for insprelio"purposes. ra
(We) agree to save, indemnify and keep harmless the City of MISC.- REFEWTO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
grant I fI is permit. nMECH.CONT. LIC.NO. MECH.
/ y�� TOTAL / TOTAL
Si n t r ppllcan/ ontractor Da UAII I-6- L. d )(902-1
INSPECTOR COPY