8132 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
1
BUILDING PROJECT IDENTIFICATION 7 PERMIT NUMBER
BUILDING APPLICATION & PERMIT
Mk
'�1 g 1NG-ELECTRICAL-PLUMBING-MECHANICAL
novirstryexm�il ' / PLAN CHECK VALIDATION
`. WW TV. ELECTRIC PERMIT FEE
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HAN A TORUTLETS-SWITCHES-RECEP 10.00/1.00
C.NO. LIGHTING FIXTURES 10.00/1.00
A TORa PPLIANCES-RESIDENTIAL 4.00
noD E
IK
PHONE PANELS 10.00 DATE OF APPLICATION-
A CmTE PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH,OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
ZIP EMP. METER OR POLE INS. 20.00
APvucalurs MOTORS SEE FEE
A D E55SCH.
OCl
SERVICE CHANGE 20.000.00
o o LICENSED CON TRACTORS DECLARATION TEMP.POLE - 30.00
rt u w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w z 'm (commencing with Section 7000)of Division 3 of the Business a BLDG. ELECT. PLG.' EC
r w z Professions Code and my license is in full force and eff t. ❑ ❑ ❑ 1
z O w - License Cl... Lic.Number - J
9 z ° DdR, q ontraclo
¢ m IE L _ BUILDING PERM(
¢ ¢ w ¢ W ILDER LIE
O '
U INFORMATION'
w0 MISC.- REFER TO ORD
3 I y I hereby ullirm that 1 um exempt Irom the Contractor's License VALUATION S/FT.
F m o j Law for the following reason.(Sec.7031.5.Businessamd Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
a ¢ ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- LL requires the applicant for such permit to file a signed statement that TOTAL P RMIT TO
a w m u, he is licensed pursuant to the provisions of the Contractor's License /
� zQ
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 D Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ I O the basis for the alleged exemption.Any violation of-Section 7031.5 STORIES T PONSTR.
by any applicant for a permit subjects the applicant toacivil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(S500).):
❑ 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 structure Is not
intended or offered for 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 FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
. meats are not hrough
ownemployees,for sale.
Ii,hOweVtsuch improve- GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00 ,
menu are not intended Or offered for wlc.1L ed that s the building
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not buil)ar im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES Into cont PB ower
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed mntruaors In construct the proieet(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
.all 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 contmctons)licensed pursuant to SEWER-SANITAR V-STORM EA.200ft/10.00
file Cuntinttor's License Law. TRACT NO. PARCEL NO.
Cl I wO exempt under Sec. ,B.&P.C.lie this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC FILE NO.
WORKERSCOMPENSA'I'ION DECLARATION WATER TREATING EQUIP, 5.00
I hereby atfinn that 1 have a cerlilicate of L ntscnl to se11-1 ISOrc, ZONING ENG.SITE NO.
ar a certificate of Workeri Compensation Ins ranee-or ace tificd
copy thereof( 3800,Lab.C.). -
Policy No. nmp,ft bilf
O ❑ Certil' d ' y is hereby furnished. FIRE SPRINK ENERGY T 24
Z ZO 4P C'ntlificd co is Ii1e w til Ih cit inspection Aivbiml. MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
CE 'I: 50 L51SS1PT N i .1 tlif �� PERMIT ISSUANCE 10.00
FLOOD ZONE A.LLLC.
LU > XON1'ENSATION NSURANCE PLG.CONTR. LIC.NO. PLG.
CL 0 1
11 hi, section need nut be completed d the pennit is for ane TOTAL Y❑ N❑ Y ❑ N[_N
hundred dOBms(5100)or less.)
U O 1 certify that in the performance of the work for which this per- GTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued, I shall not employ any person in any manner so as to
U W become subject to the Workers'Compensation Laws of California. BUILDING
C. Oum Applicant ALTER OR ADD TO MECH. 5.00
} W NOIICE TO APPLICANT: If,alter making this Certificate of Ex-
F 2 emption,you should become subject to the Worken'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this pennit shall be deemed revoked. AIR HANDLING UNIT(TO 10=11F.M.) 4.00
CONSTRUCT ION LENDING AGENCY f AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
tirepperformanceMICROFILM
rcance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00
)
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Addic ELECTRIC
I certify that I have read 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 m building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby aRIm,i,c representatives of this city to enter upon the BOILER-COMP (Over 100,000BTU)SEE FEESCH. 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,-dins-meats, costs noexpenses which PERMIT ISSUANCE 10.00 CONST.TAX
may is any fve accrue again said City in cnndcryence of the
grant of hl� crmit. C CONT. LIC.NO. MECH.
TOTAL TOTAL
Data •o APPIic t/Con fact r e
INSPECTOR