8762` APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADD Ea5
L, '? p?Cana BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 8762
NAME PLAN CHECK VALIDATION
ap J CITY. ELECTRIC PERMIT FEE
l.i OI PHONE
CONTRACTOR S
NAME ru UTLETS-SWITCHES-RECEP 10.00/1.00
e �/ uc.NO. C L LIGHTING FIXTURES 10.00/1.00
- AODe�§s TGRs / qp ['pq PPLIANCES-RESIDENTIAL 4.00
1e- 1°� D'( PHDNE sC/ -7J/ PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO,
DR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC,NO, SIGNS TRANS. '3.00
ADDRESS UNG. SPECIAL CIRCUIT 5.00 tH PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 ��
APPLIC /)
ANT'S ((` j'//
ADOREss MOTORS SEE FEE SCH. \(
SERVICE CHANGE .00
O ¢ i �p/�U•-1
, 02 LICENSED CONTRACTORS DECLARATION TEMP,POLE 30.00
¢ u u I hereby affirm that I am licensed under provisions of Chapter 9
h 2 i ISSUANCE DATE
4 (consmereing with Section 70001 of Division 3 of the Business and
BLDG. ELECT. PLG. MECH.
H o Professions Code end I y icetse is in full force'n efciX
License Class - Lic.Number
s � - Date
Contractor City 0 uper I ❑ ®' ❑
" fes
¢ a w 4 OWNER-BUILDER DECLARATION CoeP 'BUILDING PERMIT
E o ° INFORMATION' '
w 0¢w I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
uo4 Law for the following reason.(Sec.703L5,Business and Professions VALUATION S/FT.
- PERMIT ISSUANCE
La> Code:,Any city or county which requiresu permit to construct,alter,
¢ ¢ 40 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. (f"d
¢ requires the applicant for such permit to file a signed statement that
A' w m u he is licensed pursuant to he provisions of he Contractor's License PERMIT TO
FZA Law(Chapter 9(coamencingwith Section 7000)ofDivision3oi'the d-/y .5�
4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE '_/
(C H $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
iia - by any applicant fora permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more I lmn five hundred dollars(8500).):
❑ I,as owner of lite 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 thereon,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
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of completion,tiro owner-
builder will have the burden of proving that he did not build or im� GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for 1,as ownerose
of the.). INDUSTRIAL WASTE INTER. 30.00 O IND CON P❑B Gar
❑ d as owner of the property,he exclusively. 7044,ling with
licensed contractors to The
the 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 ancontracts
owner of property who builds tr improves hereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
the Cont for such projects with a contraclor(s)licensed pursuant to
the Contractor's License Lew, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO,
O I am exempt under Sec..,BAP,C.for this
reason WATER HEATER W/VENT 6.00
Owner Dale WATER SYSTEM 5.80 ACC.OATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to sel Ginsure,
or a certificate of Workers'Compensation Insumace,or a certified ZONING ENG,SITE NO.
copy Ihereof(Sec.380Q Lab.C.)
Policy No. Company �' ImRf�See rt'6e 00
11
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-34
Z ❑ Certifi• co is 'led ith the city inspection Aivision,
� O APplicant_�( MISC.- REFER TO ORD. Y❑ N❑. v ❑ N❑
OCH CERTIEICA SOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10,00 FLOOD ZONE A.L.U.C.
L31 E ,(This section need not be completd INSURANCE f hepermit is for one PLO.CONTR. LIC.NO. TLO
OTAL Y 0 N[3 Y� N0
aQ
Z hundred dollars IS 100)or less.)
U O I certify that ilwhe performance of(he work for which his per- QTY. MECHANICAh•Q(+OMIT ' FEE FEE SUMMARY, "
LL 1- mit is issued,1 shall not employ any person in any manner so as to 1"'/'+,y
Q U become subject to the Workers'Compensation Laws of California.
y Data Applicant ALTER OR ADD TO MECH. 5.001BUILDING
} W NOTICE TO APPLICANT: If,after making this Certifieate of Evx
F ? emotion,you should become subject to the Workers'Compensation APPLIANCEMOLI 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with
CJ such provisions or this permit Shut be deemed revokedFEE
'. AIR HANDLING UNIT(TO 10= 1 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLINGU F•M. .) 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
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify hal I have read this epplic.tion and State that he above VENTILATION FAN (SINGLE) 4.00
information is correct.I agree to comply with all city and county BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives ec this city es enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
hereby authorize
propertyforinsp of this
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 CONST.TAX
may in any way accrue against said City in consequence of the 10.00 Q
gran 'sgo this pe it. MECH.CONT. LIC.NO. MECH.
-.S' _XJ - TOTAL ✓ TOTAL
Signature of Iicanf ontraclor Date / ✓ x_/
OFFICE COPY