8998APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION &PERMIT
UILDING -ELECTRICAL- PLUMBING -MECHANICAL
_ PERMIT NUMBER
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8998 ^ ^ ^
BUILDING
ADDRESS
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NAM
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ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
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NDAMTEADTOR 5`
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UTLETS- SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CONTRACTORS E�
ppLIANCES-RESIDENTIAL 4.00
PANELS 10.00
DATE OF APPLICATION
TELT
OR
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
ENGINEER
LIC. NO,
SIGNS TRANS. 3.00
ADDRRESS ENG.
SPECIALCIRCUIT 5,00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
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APPLICANT'S
ADDRESS
MOTORS SEE FEE SCH,
SERVICE CHANGE 20.00
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LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
I hereby afftn that I on licensed under provisions of Chapter9
(commencing with Section 7000) of Division 3 of the Business and
Professions Cty is in full fore, ff ct.
License ClassNumrDale�ntf�cOeA�6F.CLARATION
ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
❑ ❑
BUILDING PERMIT
INFORMATION
I hereby affirmpt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Business and Professions
Code: Any city or county which requires a permit to construct, alter ,
MISC. - REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
S/FT.
ELEC. CONTR. LIC. NO. ELEC.
TOTAL
improve, demolish, or repair any structure, prior to its issuance, also
mgUjmS the applicant for Such permit tO file a Mi ed Statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
'
PERMIT TO
1.8
Business and Professions Code) or that he is exempt therefrom and
OTY. PLUMBING PERMIT FEE
the basis for the alleged exemption. Any violation of5eclion 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars ($500).):
STORIES
TYPE CONSTR.
ALTER -DRAIN -WATER IEA.) 5.00
❑ 1, as owner of the property, or my employees with wages as
their Sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
intended Or offered for sale (Sec. 7044, Business and ProfessionsDRAINS-FLOOR,
Code: The Contractor's License Law does not apply to an owner of
ROOF, AREA, COND. 5.00
FIXTURES . PER TRAP 5.00
GAS-EA.SYSTEM-i INC.40UTLETS 6,00
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve.
meets are not intended or offered for sale. If, howeveq the building
SO. FT. FLOOR AREA
TOTAL ACREAGE
or improvement is sold within one year of completion, the owner
builder will have the burden of proving that he did not build or On.
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
Prove or purpose of sale.).
❑ 1, as owner of the properly, am exclusively contracting with
RES IND CON PB Oiher
El O F-1 El 0
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon, and who
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 IEA.) 1.00
ASSESSORS PARCEL NO.
contracts for such projects with a contractoos) licensed pursuant to
the Contractor's License Law.
❑- lam exempt under Sec.-, B.&P.C. for thisWATER
reason
SEWER -$AN ITARY-STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
WORK ERS'COMPENSATION DECLARATION
WATER TREATINGEfudg"LF 5.00
1 hereby affirm that I have a certificate Of consent to self -insure.
ZONING
ENG. SITE NO.
pensaY In ranot a certifeA
). 11W1 , �1 1
Or a certificate Of r rA.Monuhhux?.
MI
ed copy is cEE' YYY
wi tl c ly pe 'on division.
npPliwnt
FIRE SPRINK
v E] N�
ENERGY TI4
v ❑ N�
MISC. I ORD.
PERMIT ISSUANCE 10.00
CER' PICATI] OF XEMPTION FROM WORKERS'
FL00o
PLG. CONTR LIC. N0. TLOO,AL
N
(This sec on need not be compION leted Rif ticl-permit is for one
v
y N
hundred dollars(S leo) or less.)
FEE SUMMARY
I certify that in the performance of the work for which this per
mit is issued, I shall not employ any person in any rimer so as to
OTY MECHANICAL PERMIT FEE
become subject to the Workers' COmpertatlon laws of California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
BUILDING
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
FEE
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions Or this permit shall be deemed revoked.
AIR HANDLING UNIT (TO 10,0MCF.M.) 4.00
AIR HANDLING UNIT (OVER 10p00C.EM.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I 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.
3097, Civ.C.).
MICROFILM
IHEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address
H EATING UN IT (OVER 100,000 B.T.U.) 9.50
ELECTRIC
VENTILATION FAN (SINGLE) 4.00
I certify that I have read this application and state that the above
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
6 Ann
BOILER- COMP (3 H.P. or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned properly for inspection purposes.
MECHANICAL
BOILER -COMP (Over 100,000 BTU)SEE FEE SCH.
(We) agree to save, indemnify and keep harmless the City of
MISC. - REFER TO ORD.
Cupertino against liabilities, judgments, costs and expenses which
ay in n way accrue against said City in consequence f t e
PERMIT ISSUANCE 10.00
CONST. TAX
ruling f permit.
5 natureclot I a[
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
l
I V OFFICE COPY