8697 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENTI FICATI ON PERMIT NUMBER
BAUO;DLflOENG APPLICATION & PERMIT 8697
O w�to BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
NAMERa 3 RC CL OYtt J
yy- T PLAN CHECK VALIDATION
• 'D I UL/ /, I ONE OTY' ELECTRIC PERMIT FEE
CONTRACTOR'S
NA Ep UTLETS-SWITCHES-RECEP 10.00/1.00
I / DLIC.NO� LIGHTING FIXTURES 10:00/1.00 -
CONTRA OHS pb(T ,Nr PPLIANCES-RESIDENTIAL 4.00
ADDRE ,/ Q /
('•V /7 9E/.V HONET1 / PANELS 10.00 DATE OF APPLICATION
ORCR ELT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO, SIGNS TRANS. 3.00
ARCH.OR
ADDRESS ENG. SPECIAL CIRCUIT 5.66 PERMIT VALIDATION
ZIP ITEMP.METER OR POLE INS. 20.00
AMOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 9S /
O o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
¢ is w I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
h a (commencing with Section 7000)of Division 3 of the Business and - BLDG. ELECT. PLG. MECH.
H m i Professions Code,and my license is in full force and effect ❑ ❑ ❑ ❑
Gz w w License Chau Lie.Number
,A H Date Contractor
P Y BUILDING PERMIT
¢ O w OWNER-BUILDER DECLARATION ^
F. °n MISC.- REFER TO ORD INFORMATION
X 3 u y I hereby affirm that 1 am exempt from the Contractor's License
FU0 < Law for the following reason.(Sec.7031.5,&Isinessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT..
mA Code:Anycity orcounty which requires a permit to construct,alter,
2 ¢ ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
ix - o rc requires Ilse applicant for such permit to file a signed statement that TOTAL PERMIT TO
w he is licensed pursuant to the provisions of the Contractor's License
8
Law(Chapter 9(commencing with Section 7000)oI'Dwisiou 3Ofthe L,
4 o business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT "FEE'
Sic m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollms($500R.): '
❑ 1,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
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 IDD SO.FT.FLOOR AREA TOTAL ACREAGE
•
himself re through his own employees.provided ev such Improve-
mtntsaremennot tiendedwithinoffered
oneyearoIf.however,the the coney- GAS-EA.SYSTEM•1INC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will[lavepurpose
the burden of proving that he did not build or int BUILDING USE
prove for purpose of the.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ d as owner Of the property,he exclusively contracting with El ❑ � ❑ ❑
licensed contractors to the priced(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The hContractor's License Law does not apply
to tr 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
the Contractor's License Law. SEWER-SANITARY-S ,2001t/10.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec..,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTE1
5.66 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION UIiCLARAT'IDN WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a certificate circuital to self-insure,
or a certificate of Workers'Compensation Insurance,or it certified Nty Of CUDerting ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lah.C.).
Policy No. C any '�
0 .❑d Ccrtifiedcop she by fur c FIRE SPRINK ENERGY T24
z Z /� Certified p is led fill -fly inspection division. ❑ ❑ ❑ ❑
F O AppRc:mt MISC.- REFER TO ORD. v N v N
X W CERTI- OF F EMPTION Fp M WORKERS' PERMIT ISSUANCE 10.00 .OD FLOOD ZONE A.L.I.C.
L MPENSATION INSU ANCE PLG.CONTR. LIC.NO. PLO,
CL 0 (This section need not be completed if the permit is for one TOTAL V N Y❑ N
::) Z hundred dollarsO 100)or less.)
U O 1 certify that in the performance of the work for which this per QTY. " MECHANICAL PERMIT FEE - - FEE SUMMARY
'LL I- mit is issued.I shall not employ any person in any manner so as to
0 w become subject to the Workers'Compensation Laws of California.
Is.
Date Applicant BUILDING
>_ 0 NOTICE TO APPLICANT: If,alter making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00 .
F ? 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
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=4 .F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10PMC.F.M.) 6.00 SEISMIC FEE
I hereby affirm find 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 UN IT(OV ER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify(hat 1 have read this application and state(flat the above VENTILATION FAN (SINGLE) 4.00Cg0
•• information is correct. I agree to comply with all city and county PLUMBING 0
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for ins of this
purposes.
(We) agree to save, ind• if mid keep harmless the City of MISC. REFER TO ORD.
Cupertino a ' bili( meats, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in wa ec it
said City in consequence of the
` grant! of per MECH.CONT. LIC.NO. MECH.
S%Z2�r TOTAL TOTAL
Signa r fAp ',ant/C n actor Date
OFFICE COPY