8310 APPLICANT TO FILL IN-INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION, PERMIT NUMBER
BUILDING APPLICATION & PERMIT 1 8310
ADORE/ n'�. BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
OWN 's WV PLAN CHECK VALIDATION
"A"' - OTY. ELECTRIC PERMIT FEE
ope PHONE
corvTRACT Rs UTLETS-SWITCHES-RECEP .10.00/1.00
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x e Lic. � TT LIGHTING FIXTURES 10.00/1.00
roNTRACTOR's
AD APPLIANCES PPLIANCES-RESIDENTIAL 4.00 '
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�/✓�/l��'� PHONE�T/'6 / PANELS 10.00 - DATE OF APPLICATION
ARCHITECT /�t PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR 0
ENGINEER
LIc.No. SIGNS TRANS. 3.00
AR. ENG. - SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
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ADDRESS
aS
s
21P EMP.METERQR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADOREss
' SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP,.POLE 30.00
<u-. hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
3 H co
H mmencing with Section 7000)of Division 3 of the Business and - DG. ELECT. I PLC. K.
F y z Professions Cod and my license is in full to d f e ❑ ❑
a, i m o License Cl _ Lic.Number
O Dal — Contractor
Q y i BUILDING PE T
E a w a OWNER-BUILDER DECLARATION INFORMATIO
A. o D MISC. REFER TO ORD
a, g' I hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
w �. o a . Law for the following reason.(Sea 7031.5,Business and Professions PERMIT ISSUANCE, 10.00
H W Code:Any city or county which requiresa permit reconstruct,alter,
2 ta Q o impmve,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 signed statement that TOTAL ERMI TO
wm he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)of Division 3 otThe r
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
the basis basis for the alleged exemption,Any violation of Section 7031.5
TORI PE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty' ALTER-DRAIN&VENT-WATER (EA.) 5,00
of not more than five hundred dollars IS 500).):
❑ 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,AR EA,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 sD:PT.FLOOR AREA TOTAL ACREAGE
. . himself or through his own employees,provided that such improve. GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00 -
ments are not intended or offered for sale.If,however,the building
or improvement is.sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or ire- RES IND CON PB Other
prove for purpose of sale.): INDUSTRIALWASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business - LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORSPARCE L 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(EA.) 1,00
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200tt/10.00 TRACT NO. PARCEL N0.
the Contractor's License Law.
❑ I am exempt under Sec,—,BAP.C.for this . WATER HEATER W/VENT.' 6.00
reason
Owner Date WATER SYSTEM -5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5,00
I hereby affirm that I have a certificate of consent to self-insure, - TONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,oXrg' certified
copy thereof(Sec.3800,Lab.0 - / /A7
Policy No. ' Company '� t9 -
O Hi' it copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z Certifi it ,yr I wi r I¢ r-ity.inspection division MISC.- - REFER TO ORD.
O Applicant V E] N[3 ❑_ NC:]
♦— y PERMIT ISSUANCE 10.00 ' •FLOOD ZONE A.L.uc.
— E RTIFICATE OF EXEMPTION FROM WORKERS'
'LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ YO N[3(This section need not be completed if the permit is for one - _ TOTAL
D Z hundred dollars($100)or less) FEE SUMMARY
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE
LL'F- mit is issued,I shall not employ any person in any manner so as to
OW become subject tothe Workers Compensation Laws of California. BUILDING
p Date Applicant ALTER OR ADD TO MECH. 5.00
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex- -
F Z emption,you should become subject to the Workers'Compensation APPLIANCE PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
CJ 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 10MC.RM.) 6.00 'SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 - -
the performance of lire work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 , MICROFILM
3097,Civ.C.).
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.0.50 ELECTRIC.
Lender's Address
—
I certify that I have read this application and state that the aboveVENTILATION FAN (SINGLE) 4.00 -
-� information is correct.1 agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of 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.ol' MISC.- REFER 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
granting-this perm).. MECH.CONI. LI .NO. MECH,
3 /P TA /O. TOTAL
Signature of Applicant/Contractor Date
/ - OFFICE COPY.