8689 (2) APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATION - PERMIT NUMBER
aUILDING APPLICATION & PERMIT
AooREss' 8689,
BUILDING-ELECTRICAL-PLUMBING.-MECHANICAL J
• o ER'3 - - PLAN CHECK VALIDATION
QTY• ELECTRIC PERMIT FEE
PHONE
/ INAMERAcaoR's UTLETS-SWITCHES-RECEP 10-00/1.00 '
sec.No. DX LIGHTING FIXTURES 46.60/1.00 ,�
nooeesSTDRs - PPLIANCES-RESIDENTIAL 4.00
- PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITEOR CTPANELS (OVER 200 AMP) 20.00 PLAN CHECK,FEE P.C.NO.
ENGINEER
ARCH.OR LIC.No. SIGNS TRANS. ' 3.00 '
ADDRESS ENG. - $PEQIAL CIRDQIT - 5.66 PERMIT VALIDATION
21P EMP.METER OR POLE INS. 20.00
APPLICANT's
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE
Dr.0 0 LICENSED CONTRACTORS DECLARATION- TEMP.POLE. 30.00
Q U U I hereby affirm that I am licensed under provisions of Chapmr Y' ISSUANCE DATE
l-a m (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r o e Professions Code,and my license is in full force and effect. ❑ ❑ ❑
z o'vl' License Class .Lie.Number
D m t w Date - 'Contractor ,
5 Y s ¢ _ OWNER-BUILDER DECLARATION rtIOO BUILDING PERMIT
a o d U INFORMATION
X ; I hereby aft'irm that I am exempt from the Contractor's License MISC.- REFER TO ORD
1- ,�m J' Law for the following reason.(Sec.7031.$,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
� w > F Code:Anyelty or Calmly which regWresa permit loconstrUCLalter,
.Q d- Q D Improve,demolish.or repair any structure,prior to its issuance.also ELEC.CONTR. � LIC.N0. ELEC. / _
am m¢ requires the applicant far such permit to file a signed statement that TOTAL 16
N whe Is licensed pursuant to the provisions of the Contractors License PERMIT TO
FiQ Law(Chapter 9(commencing with Section 7000)ofDivision 3 of the �L
F 4 O Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
M I-$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
ai - by any applicant for a permit subjects lire imnlicaut toa civil penalty. - ALTER-DRAIN -WATER IEA.) 5.60
of not more than five hundred,dollars($500).):
❑ I,as owner-
wner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE - 4.00
their sole compensation,will do the work,and tile Structure is not OCC.GROUP RES.UNITS
intended of offered far sale (See. 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 50.FT.FLOOR AREA 'TOTAL ACREAGE
himself re through his own employees,Provided that such improve-
mmselfonorintendedorofferedfer,provided
that such
building GAS-EA.SVSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion, the owner,
builder will have the burden of proving that Ise did'nat build nr im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
p g BUILDING USE
prove or follow of sale.). RES IND CON PB Other
II,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30,00
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ❑ ❑ ❑ ❑ ❑
and Professions Code:The Contractors License Law does not apply ASSESSORS PARCEL NO,
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts fur such projects with a contractors)licensed Pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
❑ 1 aempt un Sec. ,B.&P.C.for this
reason WATER HEATER W/VENT 6.00
_
Owner _ Dale WATER SYSTEM 5.00 ACC.DATE ACC.FILE No,
WORKIiRS'COMPENS ION I),C1.A RATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to Scl Ginsure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy them.1'I Sec.3800.Lab.C.).
Policy No. Company '
O ❑ •Certified Copy is hereby banished. FIRE SPRINK ENERGY TQ4
..� Z ❑ Certified copy is Oled; with the city inspection division. MISC.- - REFER TO ORD. ❑ ❑ ❑ ❑
Q APPicuat Y N V N
� T CERTI FICA1F Or EXEMPTION F ROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.c,
LU 2 COW:NSATION INSURANCE PLG.cONTR. sec.No. PLG. -
tl a (This section need not be completed if the permit is for one - TOTAL Y❑ N❑ Y ❑ N❑
Z hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
y Date Applicant- ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Iix-
Z 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
- U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10)000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY - AIRHANDLING UNIT(OVER 10PMC.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
Leader's Name
Lenders Address HEATING UNIT',(OVER 100,000 B.T.U.)9.50 ELECTRIC �b ✓ '
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
indinanc s isstatcorrect.I agree to comply with all city and county - BOILER-COMP(3 H.P.Dr 100,0006.T.U.) 6.00 PLUMBING
Ninances and slate laws relating to building construction,d co and
`. hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 10,WOBTU)SEEFEESCH.
.MECHANICAL
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, casts and expenses which CONST.TAX
may in any way accrue against sal City i consequence of the PERMIT ISSUANCE -
•:I gra f a of this -mit MECH.CONT. LIC.NO. 1E1112.0')'
L /� TOTAL TOTAL
tgnature of pylic ac t/Conlrr Uam x
OFFICE COPY -
+fit _-I�•r-�`�,:�ti��.