8725 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
PERMIT NUMBER
BOn DING APPLICATION
PROJECT IDENTI F' ':LLI
APPLICATION & t _AMIT /�
�' FCOPSES 8725 7 '/ 5
l I G —ELECTRICAL—PLUMBING—MECHANICAL U GJ
OwNER'a - _ PLAN CHECK VALIOATION
n.Me DTV'. ELECTRIC PERIYIITs�}' FEE
PHONE
NAME OUTLETS
UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No. IZA 57)Q LIGHTING FIXTURES 10.00/1.00
ADDAess TORS PPLIANCES-RESIDENTIAL 4,00
/ '7,- PANELS 10.00 DATE OF APPLICATION
ORRCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P,C.NO.
ENGINEER
LIC,NO. SIGNS TRANS. 3.00
ADD ass ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS, 2e,7CU (((
A \ADDRESS
OREss MOTORS SEE FEE SCH. I v
SERVICE CHANGE 20.00i
-02 LICIiYSED CONTRACTORS DECLARATION TEMP.POLE 30.00 /�/jl
au 1 herebyattirm that I am licensed under provisions of Chapter 9
z e, ISSUANCE DATE
y a A. (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r o a
Professions Code d my license is in full fort at ❑ ❑ ❑ ❑
License las Con raa.
ct.,,c��
? m r O% Date Contractor
BUILDING PERMIT
e w u OWNI.R-BUILDER DECLARATION
j ;LL r I hereby affirm that I am exempt from the Contractor's License
M ISC.— REFER TO ORD INFORMATION
Law for the following reason.(Sec,7031.5,Businessaud Professions PERMIT ISSUANCE VALUATION S/FT.
Code:Any city orcounty which requirsua permit to construct,alter,
m
a o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR, LIC.N0. ELEC. Z
' sem ¢ requires theapplicantpursua for the permit IO ofile f
signed statement that TOTAL �— PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License T
Fzi Law(Chapter 9lcommencingwith Section 70007ofDivision3 ofthe 6E – ,
4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT .FEE.
Se r $ the basis for the alleged exemption.Any violation of Section 703 LS STORIES TYPE CONSTR.
e- by any applicant for a permit subjects the applicant to a civil Penalty ALTER-DRAIN -WATER IEA.( 5.00
of not more than five hundred dollars IS5001.1.
❑ 1,as owner of the property,or my employees with wages as BACKFLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their Sole compensation,wit)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 o1'
• 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 awn employees,provided that such improve.
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the 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 purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 Q lO C❑ON 0 Ot❑ner
❑licensed as owner of the property,am exclusively . 7044, ing with
aPro contractors to construct 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 r owner of property who builds improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contrtractortsl licensed pursuant to
the Contractor's License Law. SEWER-SAN ITAR V-STORM EA.200tt/10.00 TRACT NO. PARCEL NO.
O I am exempt under Sec.—,BAP.C.for this WATER HEATER 111 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
WORK ERS'COMPENSATION D-DCLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a certificate ofconsent to self-insum,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(See 3800,Lab.C.1.Lr�>F*[�]/�
Policy No, Companysd I
0 ❑ tithed ropy is hereby furnished. FIRE SPRINK ENERGYT]4
Z Z ,.( CnrtifiNiNp,bed yath t city inspection division.
FO AVP icant k,'4Y �[d `CYC MISC.- REFER TO ORD. YE] NE] YC] N�
CC `6 CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. ❑C.NO. PLG.
�
Z( This section need not be completed if the permit is for one TOTAL Y[:] N� Y ❑ NE]
CJ O hundred dollars IS 100)or ten) c ,
I certify that in the Performance of the work for which this per- OTY MECHANICALYERMITy s+ FEE''' -FEE SUMMARY^
LL H out is issued,I shall not employ any person in any manner so as to - _
O Jul become subject to the Workers'Compensation Laws of California. -
y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} 0 NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z emption,you should become subject to the Workeri Compensation APPLIANCE 5.00 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 ITO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=0C.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 100,0008.T.U.)9.50
Lender's Address ELECTRIC
• I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) AEESCH.
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000B.Thereby authorize representatives of this city to enter upon the BOILER-COMP(Over IDO,000 BTU)SEMECHANICAL
above mentioned property for inspection 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 ISSUANCECONST.TAX
may in any way accrue against said City in consequence of the 10.00
granting of this permit. MECH.CONT. LIC.NO. MECH.
� L
TOTAL .
Signature of Applicant CTOTALon roc or
OFFICE COPY