8696 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATION PERMIT NUMBER
RD,LDING APPLICATION & PERMIT
ADDRESS t- --� 8696
BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
NE �
NA'ER rO Ale OUTLETS-SWITCHES-RECEP 10.00/1.00
No. ?J02'/ LIGHTING FIXTURES '4 10.00/1.00
kA FESS R /CGA/'a✓Q^,a//,,�� �/ � APPLIANCES-RESIDENTIAL 4.00
P 1 L6R 7 F _ PANELS 10.00 DATE OF APPLICATION
• APRLHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
D
ENGINEER
LIC,NO, SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION ,
ADDRESS SPECIAL CIRCUIT 5.00
ZIP TEMP.METER OR POLE INS. 20.00
APPU CANT'S MOTORS
ADDRESS SEE FEE SCH.
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a u I hereby affirm that I am licensed under provisions of Chapter 9 - ISSUANCE DATE
v, <w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT, PLG. MECH.
H, w z Professions Code,and my license is in full force and effect. '
O0 w W License Class C*:�Lie Number
m r UateCommclor - ,y
El El
¢ Q w a OWNER-BUILDF-R DECLARATION / BUILDING PERMIT
A o A D INFORMATION
w ; LL I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
LL o¢ Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00 VALUATION 8/RT.
Code:Any city orcounty which requires a permit m construct.Mier,
1
ce K Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. -LIC N0. ELEC.
K o ¢ requircs the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n w m m he is licensed pursuant to the provisions of the Contractor's License
Hzr
Law(Chapter 9 tcommeneing with Section 7000)of Division 3 ofthe ('+/�, /
i o Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE J 'V
M F o the basis for the allege)exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
ogre by any applicant for a permit subjects the applicant to a civil penolty ALTER-DRAIN (EA.) 5.00
of not more than five hundred dollars(4500).): _
❑ 1,as owner of the property.or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the stn¢ture is not
intended or offered for sada (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 does such work FIXTURES-PER TRAP 5.00 SM FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
.cuts a in not intended or ofr.red for sale.If.however,the building GAS-EA.SYSTEM-l1NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS EASYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that h - .e did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES IND CON PB Omer
m . .
❑ 1,as owner of the property,aexclusively contracting with El ElEl 1:1 11licensed contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 600 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs 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 comvusor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,B&PC,Ior this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE No.
WORK ERS'COMPENSATION DIFCLARATION WATER TREATING EQUIP. 5.00
1 hereby affnm that 1 helve a certificate ofconsen to seclfinsurc.
• or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy throof(Se,3800.Lab.0.).
Pubey No. Company
-
0 ❑ Coiled copy isbereby'famished. FIRESPRINK ENERGY T-24
z Z q,0e'rptified opy - fi wuh the cit inspection Division.
FO App lTcunt_ __� MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
PERMIT ISSUANCE 10.00
fYN CIiRTII'ICr\illi OPIiXIiAIPIION 17 ROM WO KERS' FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
0- Z (This section need not be completed if the permit is for one TOTAL v El Y E] N❑
U O hundred dollurs($100)or Iess.l
1 certify that in the perlornmhce of the work lot which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
IL H mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California. 7
a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING dO J-6} N NOI'ICIi TO APPLICANT, If,after making this Ce Nifiect of lix-
F.. Z emption,you should become subject to the Worker,Compensation APPLIANCE 5.00 PLAN CHECK
Provisions of the Labor Code, you must forthwith comply with FEE /(3 3.�%a'
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.NL) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE v
I hereby affirm that there is a construction leading agency for EXHAUST HOOD (WITH DUCT) 5.00 -
the pruourrance of the work for which this permit is issued(Sec MICROFILM
3097,CN.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name _
Lender,Address [/ HEATI NG UN IT(OV E R 100,000 B.T.U.)9.50 ELECTRIC
I certify that I Ic a 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
information
and state laws relating to building asy and c, and
hereby authorize representatives of this city to enter upon the
above mentioned property for inspection Rmpo". BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs :uW expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
grant" of this nal[. _ MECH.CONT, LIC.NO. MECH.
TOTAL TOTAL 3 4 3 -
Si atur o n pplicun/ r:m,o Datc
INSPECTOR COPY