8693 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT /
ADDRESS C
10BUILDING-ELECTRICAL-PLUMBING -MECHANICAL 8602
OW R' PLAN CHECK VALIDATION
N ME '1 QTY. ELECTRIC PERMIT FEE
PHONE '- Y
c EAPOiT To s UTLETS-SWITCHES-RECEP ]0.00/1.00
uc.ND. LIGHTING FIXTURES 1x00/1.00 �-a R PPLIANCES-RESIDENTIAL 4.00
ss _12.4
PIIONE PANELS 10.00 DATE OF APPLICATION
1,4 PANELS (OVER 200 AMP( 20.00 PLAN CHECK FEE ec,NO.
oR
ENGINEER LIC.NO SIGNS TRANS. 3.00
AARC E.08 DDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLICANT A MOTORS SEE FEE SCH.
ADOREssSERVICE CHANGE 20.00
XT
oO LICENSED CON TRACTORS DECLARATION TEMP.POLE 30.00
G
at U 1 hereby affum that I am licensed under provisions of Chapter 9 ISSUANCE DATE
m ¢ a (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H w a Profession J y license is in full f ❑
z o m - License Class Lic.Number
o z H G Uate Contractor
Mm E io) ! 51 BUILDING PERMIT
K ¢ w u OWNIi R-BUILDER DIiCLARnPION INFORMATION
od MISC.- REFER TO ORD
3 LL w I hereby affirm that I am exempt from ihu Contractor's License VALUATION $/FT.
e- o J Law for the following reason.(Sec 7031.5,Business mid Professions PERMIT ISSUANCE t.000 �.
Code:Any city or county'which requires permit to construct,alter,
at ¢¢ 0 improve,demolish.or repair any structure,prior to its issuance,also LEC.DDNTR. LIC.NQ ELEC.
o¢ requires the applicant for such permit to file a signed statement that TOTAL a PERMIT TO
w m u. he is licensed Pursuant to the provisions of the Contractor's License
H z t
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
4 Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢ m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d3 - by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(8500).1:
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEV ICE 4.00 OCC.GROUP REB.UNITS
their sole crnpensmion,will do the work,and tiro Shreiner,is not
intended or offered him sale (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 q FIXTURES-PER TRAP yr_(�
O. 50,FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve.
rents are not intended or offered for sale.If,howeve,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 IEA) 200
builder will have the burden of proving that Ile did not build or im- - . . .
BUILDING USE
prove for purpose of sale.). INDUSTRIALWASTEINTER. 3000 RES IND CON PB Omer
❑ .L as owner of the Property,me uxcluslvelY Contracting with [:] ❑ E:] ❑ [3licensed wmmetors to consimct the pmjeel (Sec.7044,Bmincss 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 lrparty who builds o.Improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL No.
❑ Iamcxemptundcr Sec ,B.&P.C.forthis WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACE.FILE NO.
W'ORKE RS'COMPENSAIION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby.11inn that I have a certificate of consent to self-insure.
or a certificate of Workers Compensation Insurance,ora Crtil'inl ZONING ENG.SITE NO.
y copy lltereot(Set.3800 Lab.C.) -
Policy NJ_ co"I
Q ❑ CeJ L c p is hereby fur she FIRE SPRINK ENERGY T-24
z Z f� ❑ Cer d �co],p�y 's file with the ci inspection division. MISC.- REFER TO ORD.
Qyj APPlican f.`'f � Y ❑ N❑ Y ❑ N❑
m CERI'I FI CATM OF EXLMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
IN LU > - CO PENSATION INSURANCE .CONTR LIC.NO. PL .
d O (This section need not be completed it tire permit is for one TOT Q Y❑ N❑ Y ❑ N❑
Z) Z hundoed dull...(8100)or less.)
U O 1,. 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL 1- 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.
Ed Date Applicant ALTER OR ADD TO MECH. 5. BUILDING
} rn NOTICE 70 APPLIGIN'I': If,after making this Certificate of Iix-
F 2 emption,you should become subject to the WorkersCompensation APPLIANCE 5.6PLAN CHECK
provisions of the Labor Code, you must liirthwith comply with a FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR INDLING UNIT(OVER 10MC.FM.) 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.). I HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name - HEATING UNIT(OVER 100,000B.T.U.19.50
Lender's Address - ELECTRIC I
I certify that I have read this tl p cation and state that the above VENTILATION FAN (SINGLE) 4.00
• information is correct I agree to c niply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 )
hereby halt o.trc representatives of this city to enter upon the
above-mentioned properly for inspection purposes. BOILER-COMP(Over 100,000 BTU(SEE FEE BCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00. CONST.TAX
may in any way accrue against said City in consequence of the
ting his permit. MECH.CONT. LIC.NO. MECH.
( ` TOTAL / �-•en, TOTAL
Iature Ali t/#Rrn7TI k Date �./
IN ECTOR COPY -