8940 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
13U LDING PROJECT I DENTI FICATI ON PERMIT NUMBER
ADDRESS APPLICATION & PERMIT 8940
AUILDIN
O BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME _ TY. ELECTRIC PERMIT FEE
PHONE
NAMERAcro s OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No. LIGHTING FIXTURES 10.00/1.00
ADDRESS APPLIANCES-
PPLIANCES-RESIDENTIAL. 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
OORRCHITEcr . PANELS (OVER 200 AMP( 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LC.No, SIGNS TRANS. 3.00
ADDRESS ENG. PERMIT CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCH. �J
SERVICE CHANGE 20.00 /
w
02 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 y✓/�
M Us u I hereby affirm that I am licensed under provisions of Chapter 9 ISS ANCE DATE
y Q % (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH,
F D a Professions Code,and my license is in full force and effect. - ❑ ❑
z y W License Class Lic.Number
o Rr
Date Contractor El
Q y F J
M ¢ ¢ OWNER-BUILDER DECLARATION - BUILDING PERMIT
i;a O INFORMATION
X g; 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
FLL0 J Law for fit a to llowing reason:(Sec.7031.5,B usiness and Pro Tessio ns' PERMIT ISSUANCE 10.00 VALUATION $/FT.
iw0F Code:Any city orcounty which requires a permit to construct,alter,
rc ¢0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.N0. ELEC.
i w m LL requires the applicant for such permit to file a signed statement Thal TOTAL PERMIT TO
he is licens'eJ pursuant m the provisions of the Contractor's License
r z i• Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
¢ Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
2 r$ • the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
e. by any applicant for a permit subjects the applicant t0 a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensatioh,will do the work•and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:1'he Con(ractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such well FIXTURES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTAL ACREAGE
• himself or through his own employees.provided that such improve.
ments are not intended or offered for sale.I L however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4(EA.) 200
builder will have the burden of proving that he did not build or im- . BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES IND CON PB Other
❑ 1,as owner of the property,am exclusively Contractin . .
g with Q Q Ej D
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 contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EAft/10.00 TRACT NO. PARCEL NO.
❑ lam clempt under Su ._ ,B.&P.C.1'nr Ibis WATER HEATER W/VEN .200 6.00
aeon
'� owner r r Date/ O�i WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATI N DECLARATION WATER TREATING 13 P. ICI? 5.00 -
I hereby affirm that 1 have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3900,Lab.C.L De Ino
Policy No. Company
0 Cl Collided copy is hereby furnished. FIRE SPRINK ENERGY T-Z4
A MI
Z 0 ❑ Certified copy is filed with the city inspection division. �
� Applicant SC.- E Efl TO ORDY D NE] Y [] N
LrLO CERTIFICATE OF(EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 Q- FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL Z (]),is action need not be completed if the permit is for one TOTAL Y N� Y O N[3
hundred dollars IS 100)or Iess.)
C..1 O I certify that in the performance of Ore work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1mit is issued, I shall not employ any person in any manner so as In
Q w hCCORIC subject to the Workers'Compensation Laws of California.
d Date Applicant ALTER OR ADD TO MECH. 500 BUILDING -
} to NOTICE 'f0 APPLICANT: If,after making this Certificate of Ex-
.
F ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Cade, you must forthwith comply with FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AG17NCY AIRHANDLING UNIT(OVER 10=C.EM.) 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 H EATING UNIT(OVER 100,000 B.T.U.)8.50
Lender's Address ELECTRIC
1 certify IhC I have read this application and state that the above VENTILATION FAN (SINGLE) 4,00
• information n correct. I agree to comply with all city and county BOILER-COMP(3 H.P.Or 100,000 B.T,U.) 6,00 PLUMBING
ordinances and slate laws relating to building construction,city
and cand
hereby authorize representatives of
this pulposus.s city to enter upon the
above-mentioned properly for ins BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
hi
(We) agree to save, indemnify and keep harmless the City o1MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
RI in any way accrue agai said City in consequence of the
g/arI/ingoflhis ermiL # ; a� MECH.CONT. LIC.NO. MECH.
•\ 11igiiat'r cif App /. TOTAL TOTAL
Slgnvtum ol'Applacanl ant/actor Uule
OFFICE COPY