8861 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATION . PERMITNUMBER
BUILDING LO APPLICATION & PERMIT -
�L BUILDING — ELECTRICAL—PLUMBING—MECHANICAL 8861
OWNER'S PLAN CHECK VALIDATION
ME OTY, ELECTRIC PERMIT FEE
ACTOR'S 11 OUTLETS-SWITCHES-RECEP 10.00/1.00
gQ ^ eC uC NO 44,47173LIGHTING FIXTURES 10.00/1.00
I.NTDRRess TORS APPLIANCES-RESIDENTIAL 4.00 aL
lyy {p„- e PHONE �J.J r PANELS 10.00 DATE OF APPLICATION
ARCHITECT Q'( 36l�Q ^
ENGINEER 1 511PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR I1�( JCC 7
LIC.No, ISIGNS TRANS. 3.00
ADDRESS ENO' SPECIALCIRCUIT 5,00 Q "' PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20,00
APPLICANTS
ADDRESS y`MOTORS SEE FEE SCH. //
vA w
SERVICE CHANGE 20.00 &/
w w o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 •j .CJ
a i w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
¢y (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F N z Professions Cr�e�,:/luny license is in full fo n ❑ ® ❑ ❑
z O u - Lice6 Chas.& 11, Lic.Number
9 m H w Date%ACEI_._. Contactor
¢ se �T�� BUILDING PERMIT
2 a w u OWNER-BUILDER DECLARATION INFORMATION
`x 3 n vHi I hereby affirm flat I am exempt from the Contractor's License MISC.— REFER TO ORD
w u O¢ Law for the following reason.(Sec.7031.5,Businessand Professions l0 VALUATION §/FT.
- g PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
2 rt¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
i w m¢ requires the applicant for such permit to file a signed statement that TOTAL s� PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
z < Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe C
i O Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
w r$ the basis for the alleged exemption.Any violation of Section 7031.5 1 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant ton civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,as owner of(he 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
Code:
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 F IXTUR ES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACHEAGE
• himself or through his own employees,provided that such impmve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the own . . .
er- GAS-EASYSTEM-OVER 4 IEA) 200 BUILDING USE
builder will have the burden of proving that Ise did not build or im- RES IND CON PB Otner
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with 1:1licensed contractors to construct tile C1 ❑ E) ❑e 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 or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contacts for such projects with a contractorfs)licensed pursuant to SEWER-SANITARY-STORM EA.20011/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec.—,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACL.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent(o self-insure,
or a certificate of Workers'Compensation Insurance,ora certified ZONING ENG.SITE NO.
copy hereO,LabCC -
PolcyNo anyC
0 ❑ Certified copy is Umby
g
furnished. FIRE SPRINK ENERGY T-24
Z Z :Certiti d coy is filed with e city inspection divisio . MISC.- REFER TO ORD.
O till l t - Y❑ N❑ Y ❑ IN C]
~ rn PERMIT ISSUANCE 10.00
LU — C RTIFICCOMONSEXEMIlTION INS RAN WORKERS' FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL Z (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y E] N❑
hundred dollars(S 100)or less.)
U O I certify that in the performance of the work for which this per. DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- 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.
Is. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W 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 (he Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M-) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10p00C.F.M.) 6.00 SEISMIC FEE ,
1 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,Cie C.).. HEATING UNIT(TO 100,000 B.T.U.) 6.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the abuve VENTILATION FAN (SINGLE) 4.00
• information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representativesof
ec Thpurposes.is city to enter upon (lie
herebymentioned proopertyertyI'orinspection ve
ILER-COMP,(Or 100,0006TUI SEE FEE SCH. MECHANICAL
h
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which
may in any way accrue ag''nst said City in c nseyucnee of the PERMIT ISSUANCE 10.00 CONST.TAX
Sm '"go thispennR. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
ature of Applican Contractor Date
OFFICE COPY