8816 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN,ONLY
BUILEMKP PROJECT IDENTIFICATION . PERMITNUMBER
N
BUILDIG - APPLICATION & PERMIT
ADDBUILDING
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL8816
1 OWNER'S PLAN CHECK VALIDATION
NAM OTY, ELECTRIC PERMIT FEE
ONE
c"Aa+MERAcroRs C v OUTLETS-SWITCHES-RECEP 10.00/1.00 -
CLar "C. ZS LIGHTING FIXTURES 10.00/1.00 37
no"cc�EACT�9 APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 I DATE OF APPLICATION
ARCHITECT
OR PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C,NO.
ENGINEER
LIC'No. ISIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 Ste, PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 20.00
ADDRES
APPLICANT'S MOTORS SEE FEE SCH. `�,((`J S/[/��(- ✓'
SERVICE CHANGE *7,'20.00
oai p
'02 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 �/ p
a .. I hereby affirm that I am liansed under provisions of Chapter 9 - ,
2 i T " } ISSUANCE DATE
H¢ H (romenorsC with Section license
I in Division of the Business and L BLDG. ELECT. PLG. MECH.
F 0 z Professions Code license is in(all r (epsj
0 4 z7 o Lirense Class Lic.Number-
u, E w Date JComrnctor - :vryryss�� CiIS'Y ❑ ❑ ❑
< y f J v Vl•F7
a w WNER-BUILDER DECLARATION BUILDING PERMIT
son
w ; N 1 hereby affirm that 1 am exempt!mm the Contractor's LicenseINFORMATION .
License MISC.- REFER TO ORD
u O¢ Lew for the following reason(Sea 703 L5,Business end Professions Q' VALUATION $)FT.
- PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit tocol suanc,also
¢ a a p improve,demolish,or repair any structure,prior 10 its issuance,also ELEC.CONTR. LIC.rv0.
a w0 LL requires the applicant for such permit to file a signed statement that TOTAL OZ/D
m he is licensed Purwanl to the provisions of the Contractor's License PERMIT TO
F z a Uw(Chapter 9(commencing with Section 7DDo)of Division 3 ofthe
s-y D Business and Professions Code)or that he is exempt therel}mn and QTY. PLUMBING PERMIT FEE /
¢ I- the basis for the ally a exemption.Any violation Of Section malty STORIES TYPE CONSTR.
a3 by any applicant fora permit subjects S500).licam toecivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollproperty,
o(my employees
❑ 1,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 C.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 don not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 5O.FT FLOOD AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale.11,however,the building GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or insprovement 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 ins- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
El 1,as owner of the property,am exclusively contracting with1:1 El El El El
licensed contractors to construct the project(Sec. 7044,BusinessLAWN SPRINKLERS- 1 INC 5 VB600 ASSEgGOR BPARCEL NO.
and Professions Code:The Contractor's License Law docs not apply V_B_ .
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
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ l am exempt under Sec. ,B.&P.C.for this
Mason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK Ii RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a cer ilicale ofermsent to self-insure,
or a certificate of Workeri Cpon rance,pT a.yertifxJ ZONING ENG.SITE NO.
ropy themd5! CIl1 i4N-S
Policy No. Co n
O ❑ Certified copy is hereby furnished.
Z Z ❑ Certified c.P/11, fie wi the my inspe lion dlvl Ion. FIRE SPRINK ENERGY T-24
O Applicant MISC.- REFER TO ORD. Y ry❑ v ❑ N[]
CERT F C EOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.0
11J MPENSATION INSURANCE PLG.CONTR. uC.NO. PC.
LG.
CL o (Thu section need not he completed if the permit is for one TOTAL Y❑ NY N�
Z) Z hundred doll...0100)or less.)
L) O 1 certify Mal in the performance W 0m work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LLL) mil is issued, I shall not employ any person in any manneras W
become subject to the Workers'Contpenwtion Laws of Califomiu.
y
O Date-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
V
provisions of the Labor Code, you must forthwith comply with FEE Loh provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M,) 4.00
CONSTRUCTION LENDING AGENCY ' AIR HANDLING UNIT(OVER 10MCF.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction Icnding agency for EXHAUST HOOD(WITH DUCT) 5.00
the PCHommnce of the work for which thio permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name .7
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC Cz/0
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information u correct 1 agree to comply with all city and county PLUMBING
ordinances end state laws relating to building construction, and BOILER-CCfaP(3 H.P.or 100,000 B.T.U.) 6.00
hereby b.ve- authorise representatOKrtyfor vas cc this city s. enter upon the BOILER-COMP (Over 10,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property(orinsp of
purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against Gabibliq,judgments, costs and expenses which PERMIT ISSUANCE 1000 CONST.TAX
may m any way rue a cost said City in consequence of the
granting Of the rm L MECH.CONT. LIC.NO. MECH.
/L TOTAL TOTAL
Si fApplica t/Contractor Dat
UIV OFFICE COPY