8313 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
BUILDING PROJECT IDENTI FICATION APPLICATION & PERMIT
NG
ADDRBUILDESS 8313
aoonessI��,s
-i/Y/ BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S
NAME ` PLAN CHECIATN
CITY. ELECTRIC PERMIT FEE
PHON,157-01 s
� AERAcioRsNM - UTLETS-SWITCHES-RECEP 111,09ff,00
uc.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR
R's
ADDRESS
PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
OR
ARCHITECT PANELS (OVER 200 AMPI 20,00 PLAN CNELK FEE P.C.NO.
ENGINEER
11C,NO. SIGNS TRANS. 3.00
ARCH,OR ENO, SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
SS
AZIP EMP.METER OR POLE INS. 20.00 )PA16
ADDRESS
MOTORS SEE FEE SCH. r
DREss ,
SERVICE CHANGE 20.00 IMAR 2 1aR�
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a u w I hereby affirm (hat 1 am licensed under provisions of Chapter 9 0-- � q
vHi a a (commencing with Section 7000)of Division 3 of the Business and BLDD, kBIWI MECH.
r o i Professions Code,and my license is in full force and effect. El
0 ei D License ClassLie.Number
Dare Contractor El
¢ m a ¢ OWNER-BUILDER DECLARATION BUILDING PERMIT
o a D INFORMATION
w; y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
HuOJ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE ,�.� VALUATION 5/1T.
��n`; � Code:Anyci(yorcounly which requires a permit to construct,alter,
IS
¢ O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTH. LIC.NO. ELEC.
A. d 0 u requires(he applicant for such permit to file a signed statement that TOTAL PERMIT TO
w m he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
K F the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil Penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ I,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 ProfessionsDRAINS-FLOOR,ROOF,AREA,GOND. 5.00
Code:The Contractor's License Law does no(apply to an owner of
property who builds or improves(hereon,and who does such work F IXTUR ES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner, GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
r ve for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 . RE5 IND tory PB Omer
1 as owner of(he property,am exclusively contracting with ❑ ❑ ❑ ❑
li used contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS 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(EA.) 1.00
contracts Cntractor's cenprojects Lwi(haconlractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ lam exempt under Sec. ,B.&P.C.Fbrthis WATER HEATER WIVENT 6.00
reason
Owner Dat WATER SYSTEM 5.00
\ ACC.DATE ACC.FILE NO,
ORKERS'COMPF.NSATION UECLARATI WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified Copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z 0 Certified copy is filed with the city inspection division. MISC- REFER TO ORD.
O Applicant - 11
Y ❑ N❑ Y❑ N[3~ (2 PERMIT ISSUANCE 10.00
6. O CERTIFICATE ONSATIOTINS FROM WORKERS' - TOTAL YO❑ 20N❑ Y❑ C N❑
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL Z (This section need not be completed if the permit is for one
hundred dollars IS 100)or less.)
U O I certify the(in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL U mit is issued,I shall no(employ any person in any manner so as to
O m become subject to the Workers'Compensation Laws of California.
y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} SO NOTICE TO APPLICANT: If,after making this Certificate of Ex-
2 emption,you should become subject to the Workeri 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 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT IOVER 10A00C.FM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
309 ' C.). e of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lend.Cv.
Lender's Name HEATING UNIT(OVER 100,000 B.T.U39.50
Lender's Address ELECTRIC
I certify that I have read thisapplicalion 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 stale laws relating to building construction, and 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. BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses whichCONST.TAX
may in any way accrue against Said City in consequence of the PERMIT ISSUANCE 10.00 -
grardAg of this permit. MECH.CONT. LIC.NO, TOTAL MECH.
car
7 BS TOTAL l
Sig re of Applicant/ContraUale
OFFICE COPY