8600 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BIt kDI NG PROJECT I DENTI FICATION PERMIT NUMBER
aO,LDss APPLICATION & PERMIT OO
AORR
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
NE PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
E
NAME
R crows OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO LIGHTING FIXTURES 10.00/1.00
AODRESSTORE PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ORRCHITECT PANELS IOVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. ISIGNS TRANS. 3.00
ARC'.OsR ENG' SPECIAL CIRCUIT - 5.00 PERMIT VALIDATION
zlv TEMP.METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 d/�S�
< u w I hereby affirm that I am licensed under provisions of Chapter 9 ISSU NCE DATE
vv,a m (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H N i Professions Code,and my license is in full force and effect. 13 E]Ow ❑ ❑
0 0 m W License Class Lie.Number MAY i 0 !985
H w H Date Contractor
¢ Y s BUILDING PERMIT
¢ ic w OWNER-BUILDER DECLARATION INFORMATION
A.
;, r I hereby affirm that I am exempt from the Contractor's License MISC.- O ORD
FUOJ Law for the following mason.(See.7031.5,Business and ProfessionspEflMIT ISSUANCE VALUATION SIFT.
u,i Code:Any city or county which requiresa permit to construct,alter, b
rt ¢ ¢�_ improve,demolish,or repair any stnrture,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
¢ requires the applicant for such permit to file a signed statement that TOTAL 6
n w m" he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
Fzi Law(Chapter 9(commencing with Section 7000)ofDivision 3 of the
¢ Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
f i o
IF H $ the basis for the alleged exemption.Any violation t ofSection malty STORIES TYPE CONSTR.
by any ofnotnpplicaa fare permit d.1lars the IS50pplicant tos civil penally ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars Imy em):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
(heir 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 Con(ructor'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 SO,FT.FLOOR AREA TOTALACREAGE
himself re through his own employees,provided that such improve-
mentsarenotintended ghhisoroffered oyees.provided
that such
building GAS-EA.SVSTEM-l1NC.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
prove for purpose of sale.). REB IND CON PB Other
❑ I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 El ❑ 13 ❑
licensed Contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 600 ASSESSORS PARCEL NO.
El
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
contmets for such projects with a contracmrts)licensed pursuant 10
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Se ,e P.C.for this WATER HEATER W/VENT 6.00
re
etc WATER SYSTEM - 5.00 ACC.DATE ACC.FILENO.
RKI:RS' ENSATI UEC ARATION WATER TREATING EQUIP. 5.00
I rely affirm that I have a certificate o consem In self-insure' ZONING
or a certificate of Workers'Compensation Insurance,ora certified ENG.SITE NO.
copy thereof(See.3BD0,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with Ole city inspection division. MISC.- REFER TO ORD.
0 Applicant y❑ No Y ❑ N❑
0 N CHAT'I FICATE OF EXEM PTION FROM WORK ERS' PERMIT ISSUANCE 10.00 FLOOD2ONE A.LU.C.
L COMPENSATION INSURANCE PLG.CONTR. ❑c.NO. PLG.
1 O (This section need not he 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 I'or which this per- OTV MECHANICAL PERMIT FEE FEE SUMMARY
LL mit is issued,I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of Califomia.
U,
Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F ? cou tion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall he deemed revoked AIR HANDLING UNIT TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00GEM.) 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,Ce.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Nddr H EATI NG UN IT(O V ER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that l have read this application and state that ttm above VENTILATION FAN (SINGLE) 4.00
information n correct I agree to comply with all city ue county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,0008.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (over 100,000 BTU)SEE FEE BCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
in ny way acerae st said City in consequence of the
antiof this perm MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Ignature. p Ica ontrac r Uate
OFFICE COPY