8320 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT
[GILDING
ADD 5 ,n/ 8320
�J BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
lN' PLAN CHECK VALIDATION
Ow E 'S
M' NA E QTY. "" ELECTRIC PERMIT FEE
}
, PHON
t CONTRA TORS UTLETS-SWITCHES-RECEP 10,0011.00
�A.
NA.Eyl
LIc.N LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00 ,
AOD 5
/$ \///�/f PHONE vf[V�i PANELS 10.00 DATE OF APPLICATION
V !V'
ARCHITECTPLAN CHECK FEE P.O.N0.
PANELS(OVER 200 AMP) 20.00
on
ENGINEER LIC.rvo. SIGNS TRANS. 3.00
ARC" OR ENG. 5.00 PERMIT VALIDATION
AODREss SPECIAL CIRCUIT
ZIP EMP.METER OR POLE INS. 20.00 ��
APPLIC
ADORE MOTORS SEE FEE SCH.
as
SERVICE CHANGE 20.00 �
Woo LICENSED CONTRACTORS DECLARATION
TEMP.POLE 30.00
ais u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
a A (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
Di Professions Co license is in full for ❑ ❑
2 O 1%,- License CI ss` Lim.Numb
o a [w Date Contractor
. BUILDING,PERMIT.
2 a w OWNER-BUILDER DECLARATION `.'_' ,INFORMATION e
w ;LL vHi I hereby afllnn that I am exempt from Ilse Contractor's License MISC.- REFER TO ORD VALUATION
S/FT.
F a. w 4 Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10.00
Code:Any ciryorcounly which requires a permit to Construct.alter, ELEC.CONTR. LIC.NO.
a ¢¢Fo improve,demolish,or repair any structure,prior to its issuance,also ELEG
D ac requires the applicant for such permit to file a signed statement that
TOTAL Q PERMIT
w$ he is licensed pursuant to the provisions of tire Contractor's License
Hii Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe -
4 o Business and Professions Code)or that he isexempt therefrom and QTY. PLUMBING PERMIT k FEE STORIES TYPE CONSTR.
¢H es the basis for the alleged exemption.Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more lhun five hundred dollars(5500).)'.
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC,GROUP 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 -
.� irifa property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.88 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employers,provided that such improve- GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00
mems are nut intended or offered for sale If,however,lire building
.j or improvement is sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or am- RES IND CON PB Orhe,
%i 1py�•'� prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
0 1,as owner of the property,am exclusively contracting with
licensed contract ars to construct the project(Sea 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
contracts for such projects with a contractor(s)licensed pursuant to SEWER-SA\1 ITARY-STORM EA.200ft/10.00 TRACT N0. PARCEL NO.
the Contractor's License Law. -
❑ l am exempt under See. .B.&P,C.for this WATER HEATER W/VENT 6.00 d
reason
Owner Dare WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compens'Iion Insurance,ora cat ified
copy��f ���
Policy
❑ ertitredc p erC yfumishe FIRE SPRINK ENERGY T-Rd,
FZ A ort i(ic�y i- I gitll thily inspection division. MISC.- REFER TO ORD.
O Q Y N V N
� N CF;RTIPICATE OIr IiX1iMP17ON''BOM WORKERS' PERMIT ISSUANCE 1b.00 ,CIO FLODD ZaNE A.L.U.C.
LLI 7 COMPfiN$ATION INSURANCE PLC.CONTR. LIC.NO. TLG
OTAL /(// Y N V N�
C- 0 (This section need not be completed if the permit is for Eric
D Z hundred dollars($100)Er less.)
L) 0 1 certify that in the performance of lire work for which this per- OTY. MECHANICAL PERMIT FEE - FEE SUMMARY'
LL H [sit is issued,1 shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California. BUILDING
Dare Applicant ALTER OR ADD TO MECH. 5.00
} N NOTICE TO APPLICANT': If,after making this Certificate of lix-
? enlption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
previsions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT"(TO 10,000 GF.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.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 HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
\ s I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 PLUMBING
information is correct. I agree to Comply with all city and county gO1LER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00
ordinances and state laws relating to building construction, and _
hereby authorize representatives of this city to enter upon the BOI LER-COMP (Over 100,000 STU)SEE FEE SCH. MECHANICAL
�1 above-mentioned property for inspection purposes.
agre to save, indemnify and keep harmless the City of MISC.-
(We) - REFER TO ORD. CONST.TAX
Cupertino lest liabilities,judgments, rosts and expanses which PERMIT ISSUANCE 10.00
may in a /may accrue against said City in consequence of the
gmp[ior [ lap i. MECH.CONT. LIC.NO, MECH.
TOTAL TOTAL 111-0-0
SignatifA plicant/Contractor c
7-4 OFFICE COPY
I �
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