8355 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS O 3 5
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL p J
OWNER'SPLAN CHECK VALIDATION
"""'E ,rI' }�� QTY. ELECTRIC PERMIT FEE
IvC C. II PHONE�S�'rJ{7l/
NAME crors OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
uc.NO. LIGHTING FIXTURES 10.00/1.00
DDRESSNTRAC ons
APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 1 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECB 7 P.C.No.
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
AARCH OR DDRESS ENG, SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 l ��
APPLICANTS MOTORS .i SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 (�
w 0 9 LICENSED CONTRACTORS DECLARATION TEMP.POLE ;y 30.00 �//( s
a u U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
Gz w (colllmencing with Section 7000)of Division 3 al the Business and BLDG. ELECT. PLG. MECH.
m i Professions Code.and my license Is in full force and effect. - E ❑ ❑ ❑
z 0 m - License Class Lic.Nmnber
9 z Oulu Contractor
a Y E BUILDING PERMIT
¢ a,w ¢ OWNER-BUILDER DECLARA PION
INFORMATION
Is LL y 1 herebyth collo thus I am exempt from the Contractor's License MISC.- - REFER TO ORD
.. 0 ¢ Law limthe following reason. 7031.5,Businessand Professions PERMITI UANCE 10.00 VALUATION $/FT.
0u Code:Any city orcounty which requires a permit to construct,after,
•"
6 e¢ Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.N0: ELEC. ,E-
0 u requires the applicant for such permit to file a signed statement that TOTAL !/-o PERMIT TO
whe is licensed pursuant to the provisions of the Contractor's License
Hii
Law(Chapter 9(commencing with Section 7000)of Uivision 3 ofthe TE"/tip? CLCG7
¢ Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ F o the basis for the alleged exemption.Any violation of Section 703 t.5 STORIES TYPE CONSTR.
e_ ?2 by any applicant for a permit subjects Ore applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not mon,than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
Iheir sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• mmseBor otingh tende ownmered for sale,
If,ed that however,
improvo- GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00 _
or improvement
are not intended or offered fur sale If,however,the building
or)der will have
is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have[he burden of proving that he did not build or im- RES IND CON PB Omer
prove 1,as owner
of lute.). INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
❑ d as owner of the properly,run project
contracting ins with
licensed contractors m construct the project ISec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Luw dues not apply
to owner of property who builds or improves .and who LAWN SPRINKLE RS-OVER 5 (EA.) 1.00
contracts
acts for such projects with a contraaor(z)licensedused pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
Cllam exempt ruder Sec. ,B.&P.C.for cis WATER HEATER W/VENT 6.00
Cl �n �1
Owner _ Date r WATER SYSTEM 5.00
ACC.DATE ACF FILE NO.
WOR ERS'COMPI.tIATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby aH1,1 fat I h .certificate ofcmisem to Self-insure, ZONING
or a certificate of Wor erg'Compensation Insurance,or a certified ENG.SITE NO.
- copy thereof(Sec.3900,Lab.CJ.
Policy No. Company
O ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division.
O Applicant MISC- REFER TO ORD. Y ❑ N❑ Y N❑
Cr rn CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOOZONE A.L.U.C.
DJ > COhIPENSATION INSURANCE • PLG.CONTE. LIC.NO. PLG.
Q. O (Phis section need not he completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per. CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL , mil is issued,I shall riot employ any person in any manner so as to
Ow become subject to the Workeri Compensation Laws of CUldornia. BUILDING
Q.
Date Applicant ALTER OR ADD TO MECH. 5.00
>_ to NO'T'ICE. TO APPLICANT: If,after making this Certificate of E..
? enlption,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must Iorthwith comply with FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10,0001C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
tire 3097,performanceCi, of tire MICROFILM
e work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Add
Lender's AddreHEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
ss
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
. information is correct. I agree to comBOILER-COMP(3 H.P.Or 100,0008.T.U.) 6.00
ply with all city and county PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to give, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgmmlls, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
gruntiogofthi permit. 1 ECH.CONT. LIC.NO. MECH.
40 1 1) Y! TOTAL TOTAL
Signa are filp licanl/C tractor ate
INSPECTOR COPY
I