8487 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
gU I LDING PROJECT I DENTIFICATI ONPERMIT NUMBER
mu,
APPLICATION & PERMIT
�0 9, Aoo
�S 'BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 8487
2.2 OWNER'S U PLAN CHECK VALIDATION
NAME Q7 �I ELECTRIC PERMIT FEE
{l, vflorvE
CONTRACTORS
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
4�2 LIGHTING FIXTURES 10.00/1.00
DO
ADDDRESSRESS R*S PPLIANCES-RESIDENTIAL 4.00
A
vHOrvE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LOC.NO, SIGNS TRANS. 3.00
ADDRESS.OR ENG. SPECIAL CIRCUIT _ 5.00 PERMIT VALIDATION /
ZIP TEMP.METER OR POLE INS. 20.00 �'O^
APPLICANT s MOTORS SEE FEE SCH.
ADDRESS
✓ 000
SERVICE CHANGE 20.00
0 0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
Q U v I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
y a w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLEC. H.
r w z Professions Code,and my license is in full force and effect. ❑ ❑ ❑
Z o m - License Class Lie.Number
w Dale Contractor
Q y E J BUILDING PERMIT
¢, Ix w¢ OWNER-BUILDER DECLARATION
o a REFER TO ORD INFORMATION
wA.y I hereby affirm that I am exempt from Ore Contractor's License MISC.-
u o ¢ Law for the following reason,(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
0 J Code:Any city or county which requiresa permit to construct,alter,
¢ ¢Q 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
wm he is licensed pursuant to the provisions of the Contractor's License
r Z aLaw(Chapter 9(commencing with Section 7000)of Division 3 ofthe
Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption.Any violation of Section 7031.$ 1 STOFNES TYPE CONSTR.
a; m 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(S5000.):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
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
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTALACREAGE
himself re through his own employees,provided that such improve-
menlsarenotintendedoraffered lot emploees provided that Suhe building GAS-EA.SVSTEM-I1NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 IEA) 200 BUILDING USE
builder will have the burden of proving that he did not build or im . . .
- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
D 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 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 for such projects with a contractors)licensed pursuant to -
theContractor'sLicenseLaw. SEWER-SAN ITARV-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam 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.
WORK E RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent Io self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lub.CJ.
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y ❑ N❑ Y ❑ N❑
~ v1 PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
� CfiRTIPIGYI'P.OF I AX IOTINS FROM WORKERS'
W �_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. vLG.
a 0 (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
Z hooded dollars($100)or less.)
0 O 1 certify that in the performance of the work for which this per- TV. MECHANICAL PERMIT FEE FEE SUMMARY
W H mit is issued,I shall no[employ any person in any manner so as to
U becorLu e' [q t�'Workers' peysutio L'wsof (orni .
f.7 CL Dalcty- A Iicant ]bre+ - BUILDING
pp ALTER OR ADD TO MECH. 5.00
} y NOT CE TO APPLICANT': If,after making this Certificate of Ex-
F Z enrption,you should become subject to the Workers'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 10pWCRIOA) 4.00
CONSTRUCTION LENDING AGENCY- - AIR HANDLING UNIT(OVER 10,000CF. .) 6.00 EISMIC FEE
1 hereby affirm that there is a construction lending agency for 031. , EXHAUST HOOD(WITH DUCT)
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T. .) 8.00 MICROFILM
3097,Civ.C.).
Lender's Name. HEATING UNIT(OVER 100,000 B.T.U.)g.50 ELECTRIC
Leader's Address
I certify that I have read this application and state that the above C V ENTI LATION FAN (SINGLE) 4,1917
-
information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000B.T.U.) 6.00 PLUMBING
ordinances and stale laws relating to M1uildin9 construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP love,1110,000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purpose.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against s' City in consequence of the PERMIT ISSUANCE
grand this permit. MECH.CONT. LIC.NO. MECH.
`/_Z5_ $5 TDT XIL6_/ TOTAL
Si fApplican mct Date
OFFICE COPY