C8411 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
.� BUI LDI NG PROJECT I DENTI
FICA* PERM
IT
NUMBER
`Di APPLICATION & PER
ADDRESS BUILDING - ELECTRICAL-PLUMBING-MECHANICALv/
46 f
OWNERS PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
• CONTRACTORS
NAME
OUTLETS-SWITCHES-RECEP 10.00/1.00
N
LIC,NO. LIGHTING FIXTURES 10.00/1.00
roNTflncToas APPLIANCES-RESIDENTIAL 4.00
ADDRESS
k' PHONE PANELS 10.00
DATE OF APPLICATION
oncwTecTPANELS (OVER 200 AMP) 20.00 vLAN CHECK FEE v.c.No.
DR
ENGINEER
i
Lie No. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION 1.
noonsss t
ZIP TEMP.&TER OR POLE INS. 20.00
I
APPLICANT 5 MOTORS SEE FEE SCH.
ADDRESS
' SERVICE CHANGE 20.00
o o
LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
cr U I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
may' (commencing with Section 7000)of Division 3 of the Business and BLD ELECT. PLG. MECH.
r y,z Professions Code,and my license is in full force and effect ❑ ❑ E]z o u, -� License Class Lic.Number,
o Z r Dots Contnafor
a Yf BUILDING PERMIT
IS Ix It st OWNISR-BUILDER DECLARATIONINFORMATION
X 3 u H I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
u0a Law for the following reason.(Sec.7031.5,Bosinessand Professions PERMIT ISSUANCE �.QO VALUATION SIFT.
RwCode:Any city or county which requiresa permit to construct, -
ap improve,demolish,of repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
0 a, requires the applicant(or such permit to file a signed statement that TOTAL 1� E MIT TO
f• a w m w he is licensed pursuant to the provisions of the Contractor's License
Fz a Law(Chapter 9(commencingwith Section 7000)of Division 3 of the
E 4 0 Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE n
M r o the basis for the alleged exemption.Any violation of Section 7031.5 ST0 TYPE CONSTR.
d ; m by any applicant for a permit subjects the applicant toacivil penalty ALTER-DRAIN&VENT-WATER IEA.) 5.00
of not more than five hundred dollars(8500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
,it Sale compensation,will do the work,and time structure is not
intended or offered to, sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,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 sa FT FLOOR AREA TOTAL ACREAGE
himself or finical,his own employees,provided that such impnrvo
ments are not intended or offered for sale.ll'.however.the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
(. builder will have the burden of proving that he did not build or iin.
L4 prove for purpose of sale.). INDUSTRIAL:WASTE INTER. - (30.00 IND ' CON PB other
:3I,as owner of the property,am exclusively contracting with 5 ❑ . ❑ ❑ ❑
( licensed contractors to construct lite project(Sec 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
Slid Professions Code The Contractors License Law does not apply If
i~ to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contacts for Such projects Lwith acontmctods licenxd pursuant to SEWER-SANITARY-STO RM EA.200ft/10;00 TRACT NO. 1 PARCEL NO.
the Contr or S s License Law.
l ❑ mm pt ct. R', ,*715+Jor this pyATER HEATER W/VENT 6.00
f,• rcasre /Jf 1
• OwI'a ' Dule WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
W'ORKIiRS'COMPENSAT ION DECLARATIO\� WATER TREATING EQUIP. 5.00 v�
I hereby affirm that I have a certificate of consent to s,H-in,.R,,
' - or It certificate of Workers'Compensation Insurance,or a certitied ZONING ENG.SITE NO.
copy Ihereof(Sec.3800,Lab.C.).
Hca T
Policy'No. Company
❑ Certified copy is hereby furnished. FIRESPRINK ENERGY T 24
m. Z Z D Certified copy is filed with the city inspection division.
r 7 MISC- REFER TO ORD.
O\ Applicant � V❑. N❑ I Y ❑ N❑
~ w PERMIT ISSUANCE 10.00 FLOOD zoNE A.L.u.c.
CERTIFICA'fli OFEXEMPTION I7ROM WORKERS'
W > COldPENSA'I'ION INSURANCE PLG.CONTR. LIC.NO. PLG.
d O (This section need cut, completed if the permit is for one TOTAL v F] N❑ Y El
Zi
." Zi Z hundred dollars(S100)or less.)
i U O 1 certify that in the performance of the work I'or which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
F m
�- LL it is issued,I shall not employ any person in any manner so as to f
U become subject to the Workeri Compensation Laws of California.
a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
'{ } to NOTICE TO APPLICANT: If,after making this Certificate of Ex
F Z emption,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
m' provisions of the Labor Code, you must forthwith comply with FEE
'( U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10)000CF.M.) 4.00
j .
CONS'T'RUCTION LENDING AGENCY r AIR HANDLING UNIT(OVER 10O00GEM.) 6.00 SEISMIC FEE
f I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
1 the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name(
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 • ELECTRIC
�
I certify that 1 have read this application and sato that the above VENTILATION FAN (SINGLE) 4.00 y
,-• information is correct I agree In comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.or 100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the f
above-mentioned property for inspection purpous. BOILER-COMP (OAi,100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to cavo, indemnify and keep hornless the City of MISC.- REFER TO ORD.
i Cupertino against liabilities,judgments, costs andexpenses which CONST.TAX
may in any way accrue against Said CA, in consequence of the PERMIT ISSUANCE 10.00
granting of this permit. MECH.CONT. LIC.NO. MECH. I \,
143 TOTAL TOTAL fQd S�
?-. Sig T,o p cant/Contractor
INSPECTOR COPY
e I