7278 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENT[FICATI ON PERMIT NUMBER
BUILDING SN APPLICATION & PERMIT 78
ADDRESS G r
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 27
�- OWNER'S PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
r Y UNE u6-
CONTRACTOR'S
CANE OUTLETS-SWITCHES-RECEP 5.00/1.00
1 ,tIN 1//1 %/ECT, uc.Co. f/ 0 LIGHTING FIXTURES 5.00/1.00 7�
_yADDRRAcroR's
. ADDRESS
CONTRACTORS
APPLIANCES-RESIDENTIAL 4.00
p / q(E JA . PRONE 7-'1111,? PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC,NON. SIGNS TRANS. 3.00
AARCH.OR DDRESS ENG SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ze EMP.METER OR POLE INS. 15.00
APPLUCArvr's p2U U.gLE ver vC
DDHEMOTORS SEE FEE SCH. C-
ASJ
,k/ pf_ . C',(-/,Z 7 SERVICE CHANGE 10.00
woo LICENSI'D CON'I'RACI ORS DECLARATION '
M U U I hereby affirm Thal 1 am licensed under provisions of Chapter 9 M ISSUANCE DATE
m ¢w (commencing with Section 7000)of Division 3 of the Business and BLOC. ELECT. PLG. MECH.
H H z Professions Code and my license is in full force and effect. El El
O m - License Class f'10 Lia Number A Y
O z Dam Z,2(_f J= Contractor
w
Q y `< J
a w¢ OWNER-BUILDER DECLARATION BUILDING PERMIT
0 o D MISC.- REFER TO ORD INFORMATION
w g u m I hereby affirm that 1 am exempt Onto the Contractor's License VALUATION SIFT.
F .. o G Law tor the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
-' Cade:Any city orcounty which requiresa permit to construct,aIle',
2 u,s- Q improve,demolish,or repair any structure,prior to its issuance,a]O ELEC.CONTR. LIC.NO. ELEC. /'�-
O IL rcyuims the applicant for such ponnil to lite a signed statement that N�/p �/ TOTAL 7. PERMIT TO
n w m he is licensed pursuant to the provisions of the Contractor's License 9
Fzi
Law(Chapter 9(commencing with Seclian 7000)of Division 3 of l he CLEC-7r
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
M
F o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR,
by any applicant for a permit subjects the applicant toe civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(S500).):
O 1,as owner of the property or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their OIC compensation,will do the work,and the structure is not
intended or offered for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code I lie 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 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
. himselfor through his own employees,provided that such improve.
m
mes arc not intended or offered for safe.ll',however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
nr improvement is sold within one year of completion, the owner- GAS-EASYSTEM-OVER 4 IEA) 100 RUILOING USE
builder,will have the burden ol'proving that he did not build or int- . . . REB IND CON PB Omer
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
CI 1,ms owner of the properly,um exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Pro1"essiuns Code Thu Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contracted,)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
0 l am exempt under Sec ,BAP C.for this WATER HEATER W/VENT 4.00
reason
Owner Dale WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to selfunsure, , ZONING ENG.SITE NO.
cocedificate of Workers'Compensation Insumme,or a certified
py IhereoflSec.3800,Luh.C.L
Policy Na. Company
O 0 Certified copy i,lienchy iornished. FIRESPRINK ENERGY T-24
Z z 17 Certified copy is filed with the city inspection division. MISC- REFER TO ORD.
0 Applicant Y ❑ IN E] Y ❑ N❑
i y CER'(IFIC'AT1:OI'Ii Xl7MP1'ION PROM WORKERS' PERMIT ISSUANCE 6.00 FLOODZONE A.L.U.C.
lL COMPENSATION INSURANCE PLG.CONTR. sec.NO. PLO_
O 11 his suction need not he completed if the permit is for one TOTAL Y❑ N❑ v ❑ N
Z hundred dollars IS 100)or les.)
U O 1 certify that in the performance of the work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mil is issued.I shall not employ any person in any manner O as to
U become subjec to the Workcrs'Co pensmt ion ws of California.
U a Dam�'�-�J_ d=Applicant ( f � '-^$/ ALTER OR ADD TO MECH. 4,00 BUILDING
} fin NOIICE'10 APPLICANT: IL after u ul�nng the Q�rinficale of I!x-
f" ? emptier,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the-Labor Code, you must forthwith comply with FEE
U such,...visions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 ? SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OV ER ress 100,000 B.T.U.)7.50 ELECTRIC
Lender's Add
I certify that l have read this application and state that he above VENTILATION FAN (SINGLE) 3.00
• info.....fine is correct. I agree to comply with all city and county PLUMBING
....linances and state laws relating lO building construction. and BOILER-ODMP(3H.P.or100,000B.T.U.) 4.00
herchy au0mrme represenmtives it 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 harmless the City of MISC.- REFER TO ORD.
Cupertino against Ilmbilities,judgmmHs, costs and axpenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence of the
r-
grantingol this permit MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
y Sgnature of pplicanl Contract Dale 4
INSPECTOR COPY