5708 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
C 7 0 8
' U 0O -t �.�c G BJ IUILDING —ELECTRICAL-PLUMBING—MECHANICAL �
OWNER'S , : - { y "%!yMq I PLAN CHECK VALIDATION
O.TfV. - ELECTRIC PERMIT FEE;..;.
Nyh
Ay. a.a coy 'IqR ry �P «x =a"•':�ry":.
[ NTRACTOR'E
NaM • , UTLETS-SWITCHES-RECEP 5.00/1.00
y LIGHTING FIXTURES 5.00/1.00
r,6 ACTORS PPLIANCES-RESIDE TIAL 4.00 ,
AII; PHON D PANELS 5.00 DATE OF APPLICATION
ORCHITECT SIGNS. 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
, uc.NO, - SIGNS TRANS. 3.00 '
ARC"OR ENG.SS: ; SPECIAL CIRCUIT .5,00 PERMIT VALIDATION
• ^ ZIP TEMP.METER OR POLE INS. 15.
APPLICANT'S - - MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATION
4
U. I hereby affirm that 1 am licensed under provisions of Chaplcr 9 ISSUANCE DATE/
y (commencing with Section 70001 of Division 3 of the Business and
¢ - BLDG. ELECT. PLG. MECH.
r Professions Code n license is in full forcgy ffec ❑ ❑
2 O s License lass Lic.Number 5 -
q Contrector� '—
-a m f=+ :BUILDING=PERMIT
¢ 0 i u OWNER-BUILDER DECLARATION �iINFORAAATION•I
in g w I- I hereby affirm that I am exempt from the Contractor's License' MISC.— REFER TO ORD -
t-,L w j Law for the following reason.(Sec.703 1.5,Business and Professions PERMIT ISSUANCE .6.00 VALUATION
S/FT.}
Code:Any cily,or county which requiresa permit to construcLalteq
in ¢ Q improve,demolish,or repair any structure,prior lO its issuance,also ELEC CONTR. LIC.NO. ELEC.
in , requires the applicant for such permit to file a signed statement that TOTAL
w m he is licensed pursuant to the provisions of the Contractor's PERMI License (yam 'LTO4)
• rzQ La.(Chapter 9(commencing with Section 7000)of Division 3 ofthe ( d-;y
E 4 'e Business and Professions Code)or that he is exempt therefrom and QTLY }_ t;PLUMBING',P,ERMIT FEE"•
¢1-$ the basis for the alleged exemption.Any violation of Section 7031.5 , - +1' r STORIES -TYPE CONSTR.
it g _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 4.00
of not more than Ove hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACKFLOW PROTECT.DEVICE 2.00
their Sale compensation,will do the work,and the structure is not -OCC.GROUP PES.UNITS
.intended or offered for sale (Sea 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4,00
Cade: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 TR AP 4.00 SOLPT.FLOORAREA TOTALACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale.Jr.however,the building GAS-EA.SVSTEM-11NC.40UTLETS 4.00
or improvement-is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 IEA.) . 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- . - RES IND CON PB Other
m
prove lot purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 RE ❑ ❑
❑ I,as owner of the property,aexclusively contracting with0 C3
licensed contractors to construct the Project(Sec. 7044,Business ' LAWN SPRINKLERS-1 INC 5 V.B. 5.00 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 SPRINKLER '(EA.) 1.00
contracts for such projects with a conlmetor(s)licensed pursuant to
the Contractor's License Law. + SEWER-SANITAR V-STOR EA.200ftI6.00 TRACT NO, PARCEL NO.
❑ lam exempt under Sec..,BAP.C.for this WATER HEAT 4.00
reason
Owner Dale WATER SYSTEM - 4,00 ACC.DATE ACC.FILE NO.
WORK F-RS'COMPENSATION DECLARATION WATER TREAT qp , I 4.00
I hereby affirm Ilial I have a certificate of consent to self-insure, ZONING. ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified .-.
Copy thereof(See.3800,Lah.C).
Policy No. Company
0/ ❑ Certified copy ishereby furnished. FIRESPRINK ENERGY T-24
Z Z picanitificd copy is Bled with the city inspection division. MISC.- - REFER TO ORD. - y[] N1:1 YE] NF]_ PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
Cr CfiR1'I PICA'TE OF EXEMPTION FROM WORKERS' -
LU > ' COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG,
Z (This section need not be completed if the permit is for one TOTAL (a t.. Y E] N❑ Y E] No
O. hundred do11,rs0I001 or less.) ,
I certify that in the performance of the work for which this per. Q j' Yy '`r�- SUMMARYi A`•µ
ty San Is issued,I shell not employ an croon in an manner so as to MECHANICAL PER1110 M- FEE L
P Y y p Y w ^i. •v'b', J
O W become subject to the Workers'Compensation Laws of California
C. Dam Applicant BUILDING
} N NO'I'IC17 TO APPLICANT: If,after making this Certificate of EX. ALTER OR ADD TO MECH. 4.00
emplion,you should become subject to the Workers'Compensation APPLIANCE - 4.00 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 10MC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER lOp00 C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. - MICROFILM
3097,Civ C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
> I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply will,all city and countya PLUMBING
ordinances and State laws relating to building construction, and BOILER-OOMP 13 H.P.Or 100,000 B.T.U.) 4.00
hereby authorise 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 3.00 CONST.TAX
may ' any way-Bectu against vid City in consequence of the
its of this permi MECH.CONT. LIC.NO. MECH. ..
TOTAL TOTAL
gnature of u. IICo a or DaIB'
OFFICE COPY