8481 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT 1 DENTI FICATI ON PERMIT NUMBER
RDILDING APPLICATION & PERMIT ��
ADDRESS
biv�-- BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
NEm PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
NCONTRACTORME s UTLETS-SWITCHES-RECEP 10.00/1.00 VL
Lc.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00 '
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT'S MOTORS SEE FEE SCH.ADDRESS
i /
SERVICE CHANGE 20.00
o LICENSED CONTRACTORS DELLA/ ION TEMP.POLE 30.00 -7/;-
0 �Js�
< u uI hereby infirm that I um licensed under pmvhsions 111 Chapter 9 ISSUANCE DATE
I G w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r s, z
O Professions Code,and my license is in full force and effect. ❑ ❑ ❑ ❑
z w - License Class Lie,Number r
o r w, Date Contractor C
a Y BUILDING PERMIT
a o a U OWNER-BUILDER DECLARATION , INFORMATION
sew 1 hereby affirm that I ani exempt from lite Contractor's License MISC.- REFER TO ORD
3 u VALUATION SIFT.
Fu0¢ Law for the ity or countywhih c.requiro 5,ermit tocnd Professions PERMIT ISSUANCE 14.00 PL
2 Code:Any city or county any structur e permit it to construct,alter.
also �f..�
¢ ¢ ¢O improve,demolish,nt repair any structure,10rfi prior n its iatement also ELEC.CONTR. LIC.NO, ELEC. 61
E7 0 a rerultt5 the applicant for such permit to file a signed statement that TOTAL /� PERMIT TO
¢ w mhe is licensed pursuant to the provisions of the Contractor's License
zin Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
E o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE Si- -v/ 1211n
¢ H the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CO MTR.
u3 � by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of tmt more t Ilan five Modred dollars($500).):
II�� I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
thdlr sole compensation,will do the work,and the structure is not
intended or offered fur sal, (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 docs such work F IXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• hinhsclf or through his own employees.provided that such""prove-
mnos are not intended or offered for sale.IL however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvenuent is sold within one year of completion, . .1 2.
the owner- GAS-EASYSTEM-OVER 4 (EA.) BUILDING USE
builder will have the burden of proving that he did not build or im- ,RES IND CON PB Omer
prove for purpose ofsal,.). INDUSTRIAL WASTE INTER. 30.00
C1 1,as owner of the property,ani exclusively contracting with ❑ ❑ ❑ ❑ ❑
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 will)builds or improves thereon.and who LAWN SPRINKLERS-OVER 5IEA.) 1.00
contracts for such projects with a amtmCtor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.KP.C.for this WATER HEATER W/VENT 6.00
'111111
T Owner Dat WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK F.RS'COM PENSA'I[ Iict.ARATIf, WATER TREATING EQUIP. . 45.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Worker.Compensation Insurance,or a certified
,copy there.f ISce.3800,Lab.CJ.
Policy N'o. Conhpany
O- ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
z Z, ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O- Applicant Y❑ N❑ Y ❑ N❑
CCN CE:R'1'IFICAI'EOFI XEMPPION FROM WORKERS' PERMIT ISSUANCE 10.00 FLooD zoNE A.L.U.C.
W 1 COM1IPENSATCN INSURANCE PLG.CONTR. LIC,NO. PL
LG. V❑ N❑ V ❑ NN[]CL Z f1 Ins section need not be completed if the pernhit is for one TOTA
hfundred dollars(S 100)or[P.,)
U O I certify that in the perfror ance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,1 shall not mnploy any person b u1Y Inm mer no us m
O W beca��L.he Workers' P'-sa m Lnws o ulifomio.I) Da1CicvntALTER OR ADD TO MECH. 5.00BUILDING /L,W NOT [CANI: If,a er hak g I I n -Z tropyou should becomeubjet In the Workr.Cc om APPLIANCE 5.00 PLAN CHECKprovof the I.a bar Code, you must forthwith comp with FEE `�
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MOC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT OVER IOAOOC.F.M.) 6.00 SEISMIC FEE Sa
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 ---
the perfommnce of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.), HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lendmlers Name
Leer's Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have Tead this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING -
ordinances and state laws relating to building construction, and BOILER-OOMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives o1this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP IDVB!100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against Ilahilitics,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
un
may in any way accrue against said City in cseruence of the h !'
grantogofth' permit. MECH.CONT. LIC.NO. MECH.
i Z611 7-44- TOTAL
'� Sire t rco u h otact Date TOTAL
% O
INSPECTOR COPY
I