8310 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL R 4 0
P31
OWNER'S PLAN CHECK VALIDATION
NAM PHONE OTY. ELECTRIC PERMIT FEE
OrrX
ONTRACT 3
NAME p� / UTLETS-SWITCHES
-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
Aoonsss
c N R'nC 7 PPLIANCES-RESIDENTIAL 4.00
O fro
ONE
17�7f{ PANELS 10.00 DATE OF APPLICATION
AR IT ° PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
GR
NGINEER
Llc.NO, SIGNS TRANS. 3.00
aoo Ess ENG. SPECIALCIRCUIT 5.0Q PERMIT VALIDATION
Z11 EMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
AooREss
SERVICE CHANGE 20.00 -
'00 I LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a u u I hereby affirm Thal I am licensed under provisions of Chapter') ISSUANCE DATE
m with Section 7000)of Division 3 of the Business and
¢z w (commencing u BLDG. ELECT. I PLG.(11 MECH.
H z I'rol'essions Code and my license is in full force and e(fecl ❑ ❑
0 o m - / License Class / Lie Number 72.2
4 H w Date Contractor1
BUILDING PERFAIT
Ie ¢ w OWNF;R-B UILUIiR DIiCLA RATION INFO Oli
wo a H 1 hcmb firm that I Bin exem t from lire Comraroo's License MISC.- REFER TO ORD
3 IL ,A y a P VALUATION
F u_ o¢ Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
Code.Any city or county which acquires a permit to construct,alter.
¢ ¢Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- 0 u requires the applicant for such permit to file a signed statement that _ TOTAL PERMIT TO
n w m m he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000).&Division 3 ofthe
¢ Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
14
IS r o the basis for the alleged exemption.Any violation of Section 7031.5 1
SfTORItS'- E CONSTR.
ate - by any applicant for a permit subjects the applicant to a civil Penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(SSOM.):
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the st ruclure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law dos not apply m 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 re through his own employees.Provided that such improve-
mentsarenotinlendedoroffereoyee sale.lf,ed that Such
Nodding GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
I,,imprmxment is sold within one year o1'completion,the owner- - -GAS EA.SYSTEM OVER 4 (EA.) 2.00
builder will have the burden of proving that lie did not build or ire- BUILDING USE
prove far purpose ofsuleJ. INDUSTRIAL WASTE INTER. 30.00 RES IND CON PR Omer
❑ 1,as owner of the property,um 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 Use does not apply
to an owner of property who builds or improves thereon.and who LAWN SPR INKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)accused pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ 1 ant exempt under Sec. ,B.AP.C.for this WATER HEATER W/VENT 6.00
reason
Owner OLD, WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSAIION UECLARAT'ION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a cetlilicule of consent to self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or u certified
copy thereof(Sec.3800,Lab,C.I
Policy No. ComPany3�-^/!.1{� (/t�
❑ en red copy rs he eby lTirnished. FIRE SPRINK ENERGY T 24
Z' Z Ce till copy Is Ilyd with lire city inspection division. _
O ciphers _ �f�ye&t�--� MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
Da
CC :I*R1IFICATF OF IiSEMP'rRTN FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
Lu > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. V❑ NEI V 1:1 N❑
CL 0 (This section need not be completed if the permit is for one TOTAL
Z) Z hundred dollars($100)ca IcssJ
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL 1- mit is issued,1 shall not employ any person in any manner so as to
U W become subject to the Workers''Cornpemsat ion Laws of California. BUILDING
n Date-Applicant ALTER OR ADD TO MECH. 5.00
} W NOTICE'10 APPLICANT: If,after making this Certificate of I's-
F Z empron,you should become subject to the Workers'Compensation APPLIANCE 5.0 PLAN CHECK
provisions of the Lob.r Code, you must forthwith comply will FEE
U such Posio0asur this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000CF.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 In, EXHAUST HOOD (WITH DUCT) 5.00
re performance of Om work for which this permit is issued(Sec MICROFILM
HEATING UNIT(TO 100,000 B.T.U.) 8.00
a
Lender's Name H ATI N G UN IT(OVER 100,000 B.T.U.)9.50
Leader's Address + ELECTRIC
I certify that l have read this application:md state that the above VENTILATION FAN (SINGLE) 4.00
information is correct.I agree 1.comply with all city anJ county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP I3 H.P.or 100,000B.T.U.) 6.00
hereby zmhorien 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 save, indemnity and keep harmless the City of MISC,- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses whichCONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10
granting 5the, ,5r itit MECH.CONT. LI .NO. ECH.
/e�7'liriW'o" TAL TOTAL
Sgn�1'Iare of Aspphcant/Contractor Dale
INSPECTOR COPY