8862 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENT[FICATION _ PERMIT NUMBER
BUILDING APPLICATION & PERMIT ^
Is �� BUILDING -ELECTRICAL-PLUMBING-MECHANICAL G
OWNER'S PLAN CHECK VALIDATION
lc CT OTY, ELECTRIC PERMIT FEE
*Ii Cbl Ql \ . PHONE
NDAMTERACTGRs UTLETS-SWITCHES-RECEP 10.00/1.00 3.)
Lie No. ( LIGHTING FIXTURES 10.00/1.00
CONTRACTORS J PPLIANCES-RESIDENTIAL 4.00
1�`e PHONE 8g-V PANELS 10.00 DATE OF APPLICATION
A CHITECT T L p �jsPLAN CHECK FEE
OR PANELS(OVER 200 AMP) 20.00
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS END' SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20 00
APPLICANT'S O i n
APPLICA MOTORS SEE FEE CCH.
SERVICECHANGE 20.00
°a TEMP.POLE
Foo LICENSED CONTRACTORS DECLARATION 30.00
Se
v v 1 hereby affirm that I am licensed under provisions of Chapter 9 - I` .. -
y< n (commencing with Section 7000)of Division 3 of the Business and ISSUANCE DATE
F to i Professions CodafPoJ license is in full for t 11
BLDG. ELECT. PLG. MECH.
Q O ie- License Class llr+ rr�Lia Number pits O BE
R
F ow DaleLY3P-1Conlructor City I.AJ
a , 2
GE w ¢ OWNER.RUILDFHE DECLARATION BUILDING PERMIT
o A D MISC.- REFER TO ORD INFORMATION
X ; w I hereby affirm that I am exempt from the Contractor's License
F lu 0 Law forthe following reason.(Sec.70313,Businessand ProfessionspERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city Or county which requires a Permit tocOnatrUCt.alter,
2 a ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. .-
A C u requires the applicant for such permit to file a signed statement that (' TOTAL OCL
PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
FZ40 Law(ChapterProfessions
Codeng )or Section is exempt therefrom
of the
E i O Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
M F o the basis for the alleged exemption.Any violation of Section malty STORIES TYPE CONSTR.
i ;m by any applicant fora permit subjects the 00.):applicant to a civil penalty
of not marc than five hundred dollars($5000.): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 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
property who builds or improves(hereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself Or through his own employees.provided that such improve
meats are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EA.SYSTEM-OVER 4 IEA.) 2.00
builder,will have th -e burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Othnr
❑ I,as owner of the property,am exclusively contracting with 11 C1 ❑ ❑ El
contractors 1G construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 00 ASSESSORS PARCEL NO.
and Professions Code:'I he Contractor's License Law does 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.200tt/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sea ,BAP.C.for this WATER HEATER W/VENT
reason 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSAT'ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure,
or a certifi[[[[[[nte of Workers'C.
Com pensoti n Insurance,or a certified ZONING ENG.SITE NO.
copy therep 0,Lub,C.l./`I(/]/ ql
Policy No//`1 0.LA ySd - l_�
Q ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY L24
Z Z 7fCertifi coy is tiled with the city inspection division. - MISC.- REFER TO ORD.
P O Plcant _ -1-)- y ❑ N❑ y ❑ N❑
CC C-RTIFICATE OF EXEMPTION FROM/WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.LU.C.
LU > COMPENSATION INSURANCE PLO.CONTR. LIC.NO. PLG,
CL o (This section need not be completed if the permit is for one TOTAL Y❑ No Y❑ No
::) Z hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not enl Ploy any person in any manner so as to
become subject to the Workeri Compensation Laws of California.
ri Dale Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} 0 NOTICE TO APPLICANT: If,after making this Certificate of Ex-
Z emption,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 10p00C-F.MI) 4,00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000CRM.) 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,Co.C.). HEATING UNIT(TO l00,0008.T.U.) 8.00
Lender's Name
Lender's Address HEATING LIN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC 0( -
I certify that 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 BOILER-WMPI3 H.P.Or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and stale Taws relating to comply
with l city and co and
hereby authorize representatives of this city to enter upon the BOILER-COMP Cost 100,000BTU)SEEFEESCH. 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 10.001CONST.TAX
a in any way accrue I ainst said City in consequence of the
Bran ng fthiSpennit / MECH.CONT. LIC.NO. MECH.
6 TOTAL TOTAL
4oingna(urc
of Applictmt/Conlractor Date '
' OFFICE COPY