8176 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION - PERMITNUMBER
BUILDING APPLICATION & PERMIT
6ADDRESS
N L'. n BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 8176
OWNER'S PLAN CHECK VALIDATION
NAME �j` OTY. ELECTRIC PERMIT FEE
• � vuoNE b���
roRs
NAMERAcOUTLETS
-SWITCHES-RECEP 46100/1.00
uc.N/O�. LIGHTING FIXTURES 10.00/1.00
n oAEss TOR's -//S/gel PPLIANCES-RESIDENTIAL 4.00
LrL 1 E 1,JZn PANELS 10.00 DATE OF APPLICATION
A rtECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC,No. ZY SIGNS TRANS. 3.00
ApDREsS ENG. - SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20,00 ^
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH. J
SERVICE CHANGE 20.00
,0o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a u w 1 hereby affum that I am licensed under provisions of Chapter 9 ISSUANCE DATE
vii< (commencing with Section 70001 of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H H i Professions Code,and my license is in full force and effect. i 1 Q ❑ ❑ ❑
Z o - License Class Lic.Number ,Z 9
Z,w -D Date Contractor -5
w
P m s-J' BUILDING PERMIT
¢a w a OWNER-BUILDER DECLARATION INFORMATION
MIS I ORD
w
on'.
LL N 1 hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
u O¢ Law for the following reason.(Sec.7031.5,Business and Professions
r - w PERMIT ISSUANCE 10.00
Code:Any city or county which requires permit to ponsuanc alter,
2 R < improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTH. LIC.NO. ELEC. /
u a 0 n requires the applicant for such permit to file a signed statement that TOTAL PERMITTO
X $ ¢ he is licensed pursuant to the provisions of the Contractor's License EL EL''
i Law(Chapter 9(commencing with Section 7000)of Division 3 of the
4 D Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
w H R the basis for the alleged exemption.Any violation of5ection 703 L5 STORIES TYPE CONSTR.
by any applicant for apermit subjects the applicant ODA civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of mo more than five hundred dollars(8500).):
❑ 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 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 SG.FT.FLOOR AREA TOTAL ACREAGE
•
himself are not hrough
own employees, le.if,ed that however,
the
improve- GAS-EA.SYSTEM-I 6.00
mems are not t is mid or offered for sale.If,however,the building
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 1,as owner
of the p INDUSTRIAL WASTE INTER. 30.00 RES IND0 0 AS Other
D❑ d as owner of the property,he 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 improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
con Coag for such projects with a contrtr actors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
theContractor's License . TRACT NO. PARCEL NO.
lexSec
❑ lam exempt under Sec. ,B.&P.C.for this
reason WATER HEATER W/VENT 6.00
"
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORK E-RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING - ENG.SITE N0.
or a certificate of Workers'Comp nsalio Insyrynq edified
copy thereof(Sec.3800,Lab.C. . ��tCti7 VI
Policy No. Compan
O ❑ Certified copy Is hereby umishesl' FIRE SPRINK ENERGY T-24
Z Z ❑ Certif d co Is fed th t Inspection division.
F O Applic:mt#��Vl W1 MISC-- REFER TO ORD. Y [:) NE3 Y ❑ ' N�
CC to CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLO, ❑ ❑
d C] ❑
o (This section need not be completed if the permit is for one TOTAL Y N Y N
Z hundred dollars(S100)or less.)
U O I certify that in the performance of the work for which this per. GTV MECHANICAL PERMIT FEE - FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner so as to
O w become subject to the Workers'Compensation Laws of California.
o, Date Appllc°nt ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F ? emption,you should become subject to filo Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the labor Code, you must forthwith comply with FEE
t.1 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(OVER 10=C.F.M.) 6.00 SEISMIC FEE
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. MICROFILM
3097,CY.C.) HEATING UNIT ITO 100,000 B.T.U.) 8.00
Lender's Adders HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify but 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-COUP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP IOver100,000BTUl SEEFEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to s ve, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against abilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
m any wn ecrue against said City in consequence of the
ant g lis Omit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
i ature ol'App icant)Cont cmr Date
OFFICE COPY