C8748 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
HU'LDING APPLICATION & PERMIT
ADDRESS
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 87481,1
OWNER P N CHECK VALIDATION
NAME QTV. ELECTRIC PERMIT FEE
PHONE
NAMER cTaRs UTLETS-SWITCHES-RECEP 10.00/1.00 -dy
sect No. LIGHTING FIXTURES 10.00/1.00
r. NTRAD H'B APPLIANCES-RESIDENTIAL 4.00
y ADDRESS
PHONE PANELS 10,06 DATE OF APPLICATION
R ° 1PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.No.
y.v ENGINEER
sec.No. SIGNS TRANS. 3.00
-ARCH.
oo Ess eNc. SPECIAL CIRCUIT 5,06 PERMIT VALIDATION
r ZIP TEMP.METER OR POLE INS. 20.00
ADDRESSTs MOTORS SEE FEE SCH. N n
/r SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
¢ u u 1 hereby,Afum that 1 am licensed under provisions of Chapter 9 1 ISSUANCE/DATE
H "' (commencing with Section 7000)of Division 3 of the Business and
a w bBLOG. ELECT. PLG. MECH.
F w z Professions Code,and my license is in full force and effect. ❑ ❑ ❑ ❑
z o v, - Licc use Class_ I ix�«r Li, NO n,bcr
Q s ts F D Date��R Contractor y
a y f �v+.�..ow' BUILDING PERMIT
¢ ¢ w a OWNIi R-BUI LLIER DISCL A' INFORMATION
-
w 3 LL
H ffirth
1 hereby am at 1 am exempt from tire MISC. REFER TO ORD
e Contractor's License VALUATION $/FT.
¢ o v, Law for the following reason.(Sec 7071.5,Businessend Professions PERMIT ISSUANCE 10
Code'.Any city or county whichrequiresapermittocnnstrucLxtler,
CE Cr¢2 improve,denholish,o,repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. EIEC.
ra LL ngmres(he applicant far such permit to file a signed statement that TOTAL E MIT TO
A w m set he is licensed pursuant to the provisinns of the Contractor's License
H z a Law(Chapter9(eommencingwlth Section 7000)ef Division Sof the
i o Business and Professions Code)or that he is exempt therefrom and QTV. PLUMBING PERMIT FEE
¢ H m the basis for the alleged exemption.Any violation of Section 7071.5 TORIE NSTR.
dg - by any applicant for a permit subjects the applicant toacivil penalty ALTER-DRAIN -WATER (EA.) $,00
-of not more than Ove hundred dol l...(8500).): ]
❑ I,as Owner of(lie property,or my employees with wages a5J
their sole compensation,will do the work,and the structure is not BACKFLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS'
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 •�
Code:I lie Contractor's License Law docs ,at 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.
himself or through his own employees,provided that such improve- _
moats are not intendedoroffe,ed for sale 11,however,the budding GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is Sold within one year Ofco...atelier,the owne.-
buildcr will have the burden of proving that he did not build or int- GAS-EA.SYSTEM-OVER 4-(EA.) 2.00 BUILDING USE j
or.,,for purpose nf.;dc). I th RES IND CON PB Other
Cl 1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE IN,TER� 30.00 ❑ ❑ ❑ ❑ ❑
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 docs not apply I -
to an owner of property who hudds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.).. 1.00
contracts for such projects with a contractorts)licensed pursuant to SEWER-SANITAR-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
O l em exempt under See. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner s Date WATER SYSTEM - 5.00 AcG DATE ACID,FILE NO.
WORKERS'COMPEN "FION DECLARATION WATER TREATING EQUIP. 5.00 U, '
I hereby affirm (hat 1 have a certificate of consent In self-insurr' ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thcrcrf LSCC 3800,Lah.CA
Policy No ompany - - -
O O.Cerol'lle c0' ¢hereby famish dr -1 FIRESPRINK ENERGY T 24
Z Z Cl Certifie c f is Elect Iwi th the city inspection division.
O Applicant L CZYrttG b MISC.- - REFER TO ORD.
Y ❑ N❑ v ❑ N❑
H - PERMIT ISSUANCE 10.00 (� FLOOD ZONE A.L.u.c.
1.ATMOF ISATION IONFRN WORKERS'
W �_ COMPENSATION INSURANCE PLG.CONTE. LIC.N0. PLG.
d O 1'1'his section need not he completed _il' the permit is for one TOTAL S W Y❑ NE] Y ❑ N❑
D Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which His per. QTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I s all not employ any person in any manner so as to
U become so et tmw'orkers'Compensation Laws of California.
O a Dale Applicant ALTER OR ADD TO MECH. 5.00 BUILDING AM S
} N No I IC17 [CANT'. It,after making this Certificate of fix.
♦- ? eruption,ym shoulA become subject m the warkeri Compcns'at ion APPLIANCE 5.00 PLAN CHECK
provisions o the Labor Code, you must forthwith comply with FEE
CJ such provisions or this permit shalt be deemed revoked. A18 HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LIaNDING AGENCY AIR HANDLING UNIT(OVER 10)000C.F.M.) 6.00 SEISMIC FEE
�T
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
themmncc of the work for which this permit is issued(Sec. MICROFILM
7097,,CiCis.v.CJ. HEATING UNIT(TO 100,000 B.T.U.I 8.00
Lender's Name leIfHEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Addrc<c�e rer ELECTRIC
I certify that lbavasthisapplication and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING i N
ordinances send state laws relating to building construction, and BOILER-COMP(3 H.Ror100,000B.T.U.) 6.00 n
hereby auu,ori,c representatives of this city m cntcr upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL ,
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and ex pens..which CONST.TAX
may in any way accrue against said City in Consequence of the PERMIT ISSUANCE 10.00
granfing0 11 p rte I MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signf a AIhis n o tractor Date
INSPECTOR COPY