8166 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT IDENTIFICATION PERMIT NUMBER
_ \ BUILDING APPLICATION & PERMIT
16
A ADDRESS
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
pL(d
ONNEWS PLAN CHECK VALIDATION
" E• Q`TY. ELECTRIC PERMIT FEE )PHONE J+-
ZSl T .SOI
NO TRACTORI
AME OUTLETS-SWITCHES-RECEP 10.00/1.00
se �T
LIC NO. LIGHTING FIXTURES 10.00/1.00 4S^
ADDRESS Rs APPLIANCES-RESIDENTIAL 4.00
CONTRAS
t, PHONE PANELS 10.00 DATE OF APPLICATION
OR
RCHITECr PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER i
1 sec.No. SIGNS TRANS. 3.00
ADDRESS ENSPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT s
ADDRESSMOTORS SEE FEE SCH. S
ADDRESS
SERVICE CHANGE 20.00
( p i
o o LICENSED CONTRACTORS DECLARATION TEMP, POLE 30.00
EE v U 1 hereby affirm that I am licensed Linder provisions of Chapter 9 ISS ANCE DATE
y' "' (commencing with Section 7000)of Division 3 of the Business and
a BLDG. ELECT. PLG. MECH.
r w z I'rulussitns Code,and my license is in full force and e(fem.
z o l„- License Claxs Lic.NumberI El
O H w Dale Contractor
a r E =1 BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDER DECLARAT ION
a.a a v INFORMATION
X 5- 1 hereby atfinn that I am exempt from the Contractor's License MISC.- REFER TO ORD I?
LL y
LLD ¢ Law for file following reason.(Sec.703 I.S.Business and Professions pERMIT ISSUANCE 10.00 VALUATION $/FT.
2 -vi Code:Any city or county whichrequo"is permit toconstruct,alter,
eaQ Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
s c ¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License
F z i
Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe
¢ Business and Professions Code)or that Ile is exempt therefrom and QTY. PLUMBING PERMIT FEE
i o
¢ r- m the basis for the alleged exemption.Any applicant
t to action malty STORIES TYPE CONSTR.
a3 � by any applicant fora permit subjects theapplicant toacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more len five hundred dollars 15500)J:
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the st Lieu rc is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Cudc:The Contractor's License Low does not apply to an owner of
property who builds or improves thereto,and who docs such work FIXTURES-PER TRAP 5.00 sa FT.FLOOR AREA TOTAL ACREAGE
linns,ments are not
hde own employees, le.ltded Imwev 'Lich improve GAS-EA.SYSTEM-11NC.4 OUTLETS 6.00
mems ore Lime intended or offered year o IL however,the building or improvement is sold within one year ofdtron,the owner- GAS EASYSTEM OVER 4 (EA) 200
builder will have the burden of proving tile he he did not mild - . - . .
or im- BUILDING USE
prove for purpose ofsaleJ. INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB omen
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
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 does 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 contraemrts)fiCCHWd pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.,
❑ I am exempt under Sec. B.&P.C.for this WATER HEATER W/VENT 6.00
reastll
Owner Ua1, WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
woRAf;RSC MPF-NATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a ecnil'i,m,of convent to self-insure. ZONING ENG.SITE NO.
ser a certificate of Workers'Compensation Insurance,or u""fif'd
copy thereof(Sec 3800,Lab C.).
Policy No. 'Company
0 ❑ Cerlified copy Is hereby furnished.
FIRE SPRINK ENERGY T]4
Z Z ❑ Certified copy is file) with the city inspection division.
F- O Applicant MISC.- REFER TO ORD. v❑ N❑ v.❑ N❑
Ire CER1'IFICA'I'E OF EXEMPTION(BOM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W > CO.MPF-NSATION INSURANCE PLG.CONTR. LIC.NO, PLG.
CL Z This section need not be completed if the permit is for one TOTAL Y F] N❑ Y E) N[]
U Q hundred dollars IS 100)or less.)
I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued, I shell not employ any person in any norm,so as to
U become subject to the Workers Compensat inn Laws of California.
C. Date Applicant ALTEWOR ADO TO MECH. 5.00 BUILDING Sts
} rn NO'110E 'f0 APPLICANT: If,after nl a king this Certificate of fix-
? Cmption,you should become subject To the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
P, ,,,ions of fila Labor Code, you most forthwith comply wit FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MOC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE 70
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.CJ. 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 Address ELECTRIC
Icertify that l 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 to building construction. and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP Inver 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,pit L Litt 'and pen's,which PERMIT ISSUANCE 10.00 CONST.TAX
may in any accrueil. against said Cit in co . gnence of lire
pr:udin I'' naMECH.CONT. LIC.NO. MECH.
/ -arc o TOTAL TOTAL �'� �O
p ill m n a Date U
INSPECTOR COPY