8257 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY ,
BU I LDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING I tBUILDIN&'-
ICATION & PERMIT
ADDRESS Q ai
moq X11 TRICAL-PLUMBING-MECHANICAL . 8Z57
OWNER'S
PLAN CHECK VALIDATION
PRGND5c'� LECTRIC PERMIT FEE
DCONTRACTOflSA E WITCHES-RECEP 10.00/1.00
n`j' uc.rvolM�VJTtJXTURES 10.00/1.00
-RESIDENTIAL 4,00
1 1 PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT
OR PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC:NO. SIGNS TRANS. 3.00 -
ARCH OR ENG.
AooREss SPECIAL CIRCUIT . 5.00 LIDATION
ZIP EMP.METER OR POLE INS. 20.00 JULpq
APPLICANT s MOTORS SEE FEE SCH. UU
.. SERVICE CHANGE 20.00
H o o LICENSED CONTRACTORS DECLARATION TEMP,POLE 30.00 City Of Cupettln0
aes u I hereby affum that I am licensed under provisions ot'Chap(er 9
y< u (commencing with Section 7000)of Division 3 of the Business end ISSUANCE DATE
H 7 i Professions Co an 'cense is in full fo - BLDG. ELECT. PLG.
0 i vwi o Licens la^ ' Lie.Numb r ❑ ❑ ❑
r w H J Date Contractor
¢_ w a OWNER-BUILDER DECLARATION BUILDING PERMIT
M MISC.- REFER TO ORD INFORMATION
X o u H I hereby affirm that I em exempt from the Contractor's License
u O ¢ Law for the following reason.(Sec.7031.5,Business and Professions VALUATION
�0 � Code:Any city orcounty which requires a permit to construct,alter, PERMIT ISSUANCE 10.00
2 ¢ Q 0 improve,demolish,or repair any structure,prior to its issuance,also .ELEC.CONTR. LIC.NO.
ELEC.
O u requires the applicant for such permit to file a to
statement that TOTAL PER
TO
a w S w he is licensed pursuant to the provisions of the Contractor's License
HiQ
Law(chapter 9(commencing with Section 7000)of Division 3 of(he
4 O Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE e
H m the basis for the alleged exemption.Any violation of Section 7031.5
STORIESV. TYPE CONSTR.
a. by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(8500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4,00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure 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 does such work FIXTURES-PER TRAP 5.00 so.FT.FLoofl AREA TOTAL ACREAGE
himself ments re through his own employees provided that such improve.
orimprovemenotnn tended or within
red one or Sale.year
icomplever,tion the the owner, GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00R S I❑ ❑N PB El 1:1❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Boslness LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 gsSE550R5 PARCEL NO.
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-OVER 5 IEA.) 1.00
contracts for such projects with a contractorfs)licensed pursuant to -
theContractor'sLicenseLaw. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec..,B,&p.C.for this
reason WATER HEATER W/VENT 8.00
Owner Date WATER SYSTEM - 5.00
ACC.DATE , ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 '
1 hereby affirm that I have a certificate of consent to self-insure,
or a certificate
�ao�f�WorWwgo0rQ�ke'rrs���'yyyCompennsation I(rnssurrnccee,,,.or acertified ZONING ENG.SITE NO.
copy the N�+]k�.iAl� \,�,
Policy 1
(] ❑�erNfied copy is hereby furnished FIRE SPRINK ENERGYT-
' Z Z 1�
Ce 0 i B ��h rFr y spec, Pa
p Applicant l�•]I 1� MISC.- REFER TO ORD. -Y NQ -+YE] N�
CC y CERTIFICATE OF-EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE y A.L.U.C.
WCOMPEION
> (This section need noN beTcampleted INSURANCE
theTOTAL V N Y NEpennil is for one PLG.CONTR. LIC.NO.
CL
a o '
L=) Z hundred dollars 1$100)or less.)
) 0 I certify that in the performance of the work for which this per- O•EY MECHANICAL PERMIT FEE FEE SUMMARY
LL U mil is issued,I shall not employ any person in any manner so as to
O m become subject to the Workers'Compensation Laws of California.
to Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to .NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F ? emprovisions of the Labor Code, you must forthwith comply with ption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
-U such provisions or(his permit.shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.RM.) 6.00 SEISMIC FEE
I hereby affum 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
Lender's Address HEATI NG UN IT ER 100,000 B.T.U.)9.50 ELECTRIC
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 and County PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP.(3 H.P.or 100,000B.T.U.) 6.00 '
,hereby authorize representatives of,this city t0'entet upod the BOILER-COMP lover loo,000 Brul SEE FEE seH. MECHANICAL
above-mentioned property for inspection purposes. .
(We) agree to save, indemnify and keep harmless the City of MIS .- /0 . ER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE - 10.00 lluvu
graf this er iL n MECH.CONT. -LIC.N0. MECH. -
` I�n� TOTAL 14C TOTAL i
'g re o Applicant/Contractor Dat �F.{'tl I Ove
OFFICE COPY