8776 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING C APPLICATION & PERMIT
ADDRESSxILDING - ELECTRICAL-PLUMBING-MECHANICAL 8776 77r
PLAN CHECK VALIDATION
NAME _q I ELECTRIC PERMIT FEE
. PNONE - ,
ONTR TORS
NAME ��1V/�� OUTLETS-SWITCHES-RECEP 10,0011.00
1P 1 01. LIGHTING FIXTURES' 10.00/1.00
CONTRIICTT.'S '
ADOR s _ ci- APPLIANCES-RESIDENTIAL 4.00
tPHON�Al PANELS , 10.00 DATE OF APPLICATION
0gcHn Ec - PANELS (OVER 200 AMP) - 20.00 PLAN CHECK FEE P.C.Na.
ENGINEER -
' LIC.No. ' SIGNS TRANS. ' - - 3.00
moo ESS ENG' SPECIALCIRCUIT 5.0Q PERMIT VALIDATION
ZIP ITEMP.METER OR POLE INS., 20.00 J_
APPLICANT
ADDRORIi - MOTORS SEE FEE SCH.
ill
SERVICE CHANGE 20.00
r
IS o LICENSBU CONTRACTORS DECLARATION TEMP.POLE 30:00
a mo u 1 hereby inform that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
H 1 A. (commencing with Section 7000)of Division 3 of the Business and -eBLDG. ELECT. PLG. MECH.
z Professions Code,and my license is in full forc
o i0 mne f - ❑. ❑ ❑
o License Class sc.Number
F w H J Dule Ccmtowlor - -
M :e ' - - BUILDING PERMIT '
E 0 a O OW R-BUILDER UEChARATI N . ' INFORMATION
3 LL y I hereby affirm that I am.exempl from.the Contractor's License MISC.- •REFER TO ORD
u 0 at Law frr the following"Ann.(Sec:703 1.5,Business and Professions VALUATION $/FT.
- PERMIT ISSUANCE; 10.00
Code:Any city or county which requirese permit to construct,,also
tort < 0 improve,he applicant
nr for such
h p structure,prior In its issuance,also ELEC.CONTR. ,LIC.NO. ELEC.
DLL requires the applicant for such permit to file a signed statement that TOTAL qPERMIT TO
n w m he is licensed pursuant to the provisions of the Contractor's License : / L D
r z i Law(Chapter 9(commencing with Section 7000) rDivision 3 ofthe r C-T
st Business and Professions Code)or that he is exempt therefrom and QTV,. PLUMBING PERMIT FEE
W r D the basis for the alleged exemption.An _
g P the
tSectionenalty STORIES TYPE CONSTR.
i ;$ by any applicant ore permit subjects the applicum ro a civil penalty
of not more floor iive hundred dollars18500).): ALTER-DRAIN&'VENT-WATER (EA.),5.00
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole'compensalion,will dothework,and the structure is not
intended or offered for sale(See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:Tire 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-
+� me ms are not intended or offered for sale,If,however,the building GAS-EA.SYSTEM',-11NC.4 OUTLETS 6,00 • r
or improvement is sold within one year of completion,the owner- _GAS,,EASYSTEM-OVER IEA,) 2.00, BUILDING USE
builder will have the burden of proving that he did not build or am. . - . RES IND CON PB Omer
prove for purpose of sale.). - INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ , ❑ 0 ❑
licensed 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 an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractur(s)licensed pursuant to SEWER-SANITARYV-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO,
❑ 1 am exempt under Sec.• ,B.E.P.C.for thisWATER HEATER W/VENT 6.00
reason
. . Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPIiNSATION DECLARATION '• WATER TREATING EQUIP, 5.00
I hereby affirm that I have acertificate ofconsenl Ioscit-blare, ZONING or a certificate of Workcrs'Compe alio..Insure-c,nr a rtlit led ENG.SITE NO,
c�opQyy �{���ry���0'jfp
OC),
Q WN �crYiYled copy n he by turn he FIRE SPRINK - ENERGV T-Y4
Z 2 ❑ Cert c cap i Xt
I•d wit, t �q ly4 division. MISC.- - R T U.O APPlican( �,(k .- ❑ N❑ v ❑ N❑ .
~ rid PERMIT ISSUANCE 10.00
LU - CIiR ICCOM OP COMPENSATION
TION PROh1 WORKERS' LOOD ZONE A.L.u.a�
W COMPIiNSATION INSURANCE - PLG.CONTR. - cit tV C f(qJ PLG.
CIE, Z Y rbis section need not be completed if the permit is for one sl TOTAL V❑ N❑ V ❑ N❑
O hundred dollars(5100)or less.) -
I certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE • .FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any esu nide,so as to
O w became subject to the Worke,i Conrpensutlon Laws of California.
tt Date Applicant BUILDING
>- rid NOTICE 'f0 APPLICANT: H.alter making this Certificate of Ex- ALTER OR ADD TO MECH. 5,00
F- 2 emotion,you should become subject In the Workers'Compensation - APPLIANCE 5.00 PLAN CHECK
pro00
visions of the Labor Code, you nmsl forthwith comply with FEE
U such provisions or this permit shall be deemed revoked, _ AIR HANDLING UNIT(TO 1Q0C.F.M.) 4.00
CONSTRUCTION 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 lite work for which this permit is issued(Sec. - MICROFILM
3097,CO,C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00 -
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC
I certify that l havenoul this application and State(had theahove VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county (3 PLUMBING
b.o
. ordinances and slate laws relating to building construction, andBOILER-COMPH.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives for ins inspection
this city (n enter upon tire BOILER-COMP (Over 100,000 BTU)SEE F E E SCH. MECHANICAL
above-mentioned property forinsp of
purposes
(We) agree to save, indemnify and keep harmless the City of MISC.- - REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of tire PERMIT ISSUANCE 10.00
gr ting of lit' ermit. /\N MECH.CONT. LIC.NO. MECH. ^ `TOTAL TOTAL rv,
Sion tur ic:et/Contractor D (c
OFFICE COPY' - - -