8927 n APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
IM) BUI LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 8927
ADDRESS
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
PLAN CHECK VALIDATION
OTV. ELECTRIC PERMIT FEE
PRONE
±
NAMERAc7oms UTLETS-SWITCHES-RECEP 10.00/1.00 J.
LIC.No. LIGHTING FIXTURES 10.00/1.00
ADD
RessroRs PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
08
ARCHITECT
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE 20,00 )
APPLICANT'S MOTORS FEE SCH. �;/1'
_ ,r'-�^_
ADDRESS
SERVICECHANGE rf ..;20.00 O -o LICENSED CONTRACTORS DECLARATION TEMP.POLE t 30.00 Q "
o I hereby affirm_that I am licensed under provisions of Chapter 9 ISSUANCE DATE
Z w (commencing with Section 7000)of Division 3 of the Business and
BLDG. ELECT. PLG. MECH,
G D ty of cupertion
iProfessions Code,and my license is in full force and effect. ❑ ❑ ❑
Z i v"i a License Class Lie.Number �/kA
Q Date Contractor .9 .
Q y f J /
g a w ¢ OWNER-BUILDER DECLARATION BUILDING PERMIT
;a. N I hereby affirm that I am exempt from,the Contractor's License
MISC. REFER TO ORD INFORMATION
u, v_ o J Law for the following reason.(Sec.703 1.5,Business and Professions PERMIT ISSUANCE 10.00 6 VALUATION S/FT.
mFir Code:Any city or county which requires a permit to construct,alter,
¢ 2 ¢o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. q
a F O u requires the applicant for such permit to file a signed statement that TOTAL eJ V PERMIT TO
wm he is licensed pursuant to the provisions of the Contractor's License
Hi > Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe
f 4 o Business and Professions Code)or that he is exempttherefromand OTY. PLUMBING PERMIT FEE
¢ H $ 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&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wagesas BACK FLOW PROTECT. DEVICE 4.00 OCC.GHOUP 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 SQ FT.FLOOR AREA TOTAL ACREAGE
mntahimself m through his own fiend fors,Provided that such improve.building
,
mo through
ot dad on employees,
eesule.Iided(hat such
building GAS-EA.SVSTEM-11NC.40UTLETS 8.00
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.). RES IND CON PB Other
❑ 1,as..net at theproperty, - INDUSTRIAL WASTE INTER. 30.00 11 11 El El 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 Contractors 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 SEWER-SAN V-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL O.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reaso
Ow Date WATER SYSTEM 5.00 PCC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(See3800,Loth.C).
Policy No. - Company '
0 ❑ Certified copy is hereby furnished. FIRE gPRINK ENERGY T24
O A Applicant
licaEll ndified copy is filed with the city inspection division. MISC.- REFER TO ORD. y N v N
❑ ❑ [3 ❑
CCT C17RTIFICATE0F F-XF-MPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
W ? COMPENSATION INSURANC17 PLG.CONTR. LIC.NO. PLG.
(L O ('this section need not be completed if the permit is for one TOTAL Y❑ N Y❑ N❑
CD Z hundred dollars(S 100)or less.)
U O 1 certify Det in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL j- 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.
n Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} Us NOTICE TO APPLICANT: If,after making this Certificate of Ex-
? emptlon,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 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.RM.) 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,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name H EATING UNIT(OVER 100,000 B.T.U.)9.50 30
Lender's Address ELECTRIC I C
1 certify dna(I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information n correct I agree to comply with all city and county PLUMBING
information
and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.1.8.00
hereby authorize representatives of this city to enter upon the
above-mentioned property 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 which PERMIT ISSUANCE 10.00 CONST.TAX
may in any wry,aceru gamat said City in consequence of the
g Ing of lhss ren MECH.CONT. LIQ NO. MECH.
TOTAL TOTAL
Signature of App icaN/Can Vaelor ate I
OFFICE COPY