C8641 I' APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
' BUILD ING PROJECT I DENT[F I CATION PERMIT NUMBER
yBUILOtNG APPLICATION & PERMIT
AooEEss A
I ` C BUILDING -ELECTRICAL-PLUMBING -MECHANICAL 8641
OWNER'S - - _ PLAN CHECK VALIDATION
NAMEOTY. ELECTRIC PERMIT FEE
LAG N L PRDNE 73-71
�
NAMERACTOR's UTLETS-SWITCHES-RECEP 10.00/1.00
Q,,�(N-( e LIC.NO. LIGHTING FIXTURES 10.00/1.00
ADOR's
ADDRESS PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT - PANELS (OVER 200 AMP) 20,00 PLAN CHEC77 P.C.NO.
OR
ENGINEER
I uc.No. SIGNS TRANS. 3.00
u, ADDRiESS ENG. SPECIAL CIRCUIT 5.00 � PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
•
ADDRESS 54__/ �/
SERVICE CHANGE 20.00
0 0 o LICENSED CONTRACTORS D17CLARATION TEMP.POLE 30.00
¢ v U I hereby affrnl that 1 am licensed under Provisions of Chapter 9 ISSUANCE DATE
wa $ (commencing with Section 7000)of Division 3 of the Business and BLDG ELECT. PLG. MECH.
H y z Professions Code,and my license is in full force and effect ❑ El ❑
Z o y - License Class Lie.Number
4 y w Date Contractor
a m BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDER DECLARATION
o d o INFORMATION
I hereby of lino that I ant exenua from the Contractors License MISC.- REFER TO ORD
W 0 G y I VALUATION
FwOj Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
¢ ¢ Q improve,demolish,or repairany structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. \
AR
- D ¢ requires the applicant for such permit tot it,a signed stalentent that TOTAL PERMIT TO
Cs he is licensed pursuant to the provisions of the Contractor's License
H z r
Law(Chapter 9(commencing`*'ith Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ F the basis for the alleged exemption.Any violation ofSection 7031.5 STORIES TYPE CONSTR.
w , by any applieaut for a permit subjects the applicant to a civil Pcnully ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(5500).1:
❑ I,as owner of Om properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole contpenution,will do IIIc work,and the structure is not
intended or offered for sale (Sec. 7044, Business cud I, If scions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an pwner of
property who builds or improves thereon,and who does sEch work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.Provided that such'improvc-
memsarenotintendedorofferedforsale.If,however,Die building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or im- LDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 EEB IND CON PB other
❑ I,as owner of the property,mm exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 1ASSESSUHS PARCEL NO.
'- and Professions code: rhe 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 contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am cxemptonder Sc, ,B.&P.C.lin this WATER HEATER W/VENT 6.00
reason
Owner4 OK Dale ff� WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORKI!RS'CO I SA N DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ul consent to self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(See.3800,Lab.C.L
Polity No. Company
0 ❑ Certified copy is hereby furnished. FIRESPRINK ENERGY T-24
Z Z ❑ Certified copy is fled with the city inspection division. MISC.- REFER TOORD-
Q Applicant Y❑ N❑ Y ❑ IN[3
Ir W CERT[P[CATF OI'EXEMP IION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
LU > COhIPENSATION INSURANCE: PLG.CONTE. LIC.NO. 'PLG.
CL Z frhis Section need not be completed if the permit is for one TOTAL Y[:] NE] Y E] N❑
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
IL H mit is issued,I shall not employ any person in any amnio,so as to
O become subject to the Workers'Compensation Laws of California.
a Dam Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ ED NOTICE TO APPLICANT If,alter making this Certificate of Ex-
FZ 1210.
cmplion,you should be come subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shat[be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER10MDC.EM.) 6.00 SEISMIC FEE
I hereby' affirm that there is a construction lending agency for EXHAUST HOOD(WITITDUCT) 5.00
tire3097.eLance of the work for which this permit is issued(See. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 /
Lender's Address ELECTRIC
1 certify that I have read this application and slate 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 13 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify andkeep harmless the City of MISC.- REFER TO ORD.
,Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said OY in consequence of the PERMIT ISSUANCE 10.00
granting o fit is pen MECH.CONT. LIC.NO. MECH.
6 TOTAL TOTAL
Signet r of Applicant/Contractor ate
INSPECTOR COPY 31� 010