8313 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FI CATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT �^�
ADDRESS S
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
�� NATI
DINNER Ji_ N PLAN CHECK VALIDATION
NAME ?21 XV DTV. ELECTRIC PERMIT FEE
ERIC- ry
NAMER"croRsUTLETS-SWITCHES-RECEP lg.01 :00
LIC.NO. LIGHTING FIXTURES 10.00/1.00 ^
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT �., PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0,
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
AARCH OR
DDRESS E"f ♦ SPECIAL CIRCUIT 5,00 r+ PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 `
APPU MOTORS SEE FEE SCH.
ADDUDDRE55SS
SERVICE CHANGE 20.00
oo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
Q mo v I hereby affrm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
n<w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H w z Professions Code,and my license is in full force and effect ,y._ ❑ ❑
o 0 m o License Class Lie.Number s T
Dale Contractor
Ha Y BUILDING PERMIT
Ix ¢O i U OWNL'R-BUILDIiR DECLARATION RATION INFORMATION
,4 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
3 LL VALUATION $/FT.
`sew .. o¢ Law for the following reason(Sec.7031.5.Business and Professions PERMIT ISSUANCE i
w0 Code:Any city orwwVy which rcquiresa permit to cnnstnet,alteq
2 rt a a improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC,NO. ELEC.
BE requires the applicant for Such permit to file a signed statement that TOTAL PERMIT TO
A wis" he is licensed pursuant to the provisions of the Contractor's License
HZQ
Law(Chapter 9(commeneing with Section 7000)of Division 3 fthe
i O Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
lire basis for the alleged exemption.Any violation of Section 7031.5 1 STORIES TYPE CONSTR.
is. by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500)):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and 1'rofcssions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:'fisc 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 S°.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provide)that such impnrvo .
mems are not through his orofficood for employeesa c.provided
thathowevS,the building GAS-EA.SYSTEM-l1NC.40UTLETS 6.00
or improvement is sold,wilhin one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or ins- BUILDING USE
pr for purposa Of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON RB Other
I,r owner of the property,am exclusively contracting with ( ❑ ❑ ❑ ❑
II •hued contractors to construct the project (Sec.7044,Business LAWN SPRINKLERS-I INC 5 V.6. 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 contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I ant exempt tinder Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
ORKII RS'COMPENSATION DFCLA RATTOK WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.3800,Lab.CA
Policy No. Company
0 ❑ Certified copy is hereby lumished. FIRE SPRINK ENERGY T 24
z p A 0lieCertified copy is filed with tare city inspection division. MISC.- REFER TO ORD. v ❑ N❑ v ❑ N❑
~�w PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
LU - GiIYI'1FIG1'I'1>OFIiAl]ON IONPROh1 WORKIiRS'
W COM not be coo INSURANCE thePLG.CONTR. LIC.N0. PLG. Y❑ N❑ Y❑ N❑
Z (This section need not be complete) it the permit is for one TOTAL
hundreA dollars IS 1001 or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit n issued,I shall not employ any person in any manner so as to
oU become subject to tire ie WorkerCompensation Laws of California BUILDING
a Date Applicant ALTER OR ADD TO MECH. 5.00
} W NOTICE "TO APPLICANT. If,after making this Certificate of lix-
F Z emption,you should become subject to the Workers'Compensut ion APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=1 C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10SMC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construmtian lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the 3097.Tied
CivC jn<e nl'the work for which this pennMICROFILM
ill is issue)(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 Address ELECTRIC
I certify that l have read this application and state that the above VENTI LATION FAN (SING LE) 4.00
a Donation is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, anJBOILER-COMPH.P.or100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the SOI LER-COMP(3(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above mentioned property for inspection purposes.
(We) agree m save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
grantin•of this permit MECH.CONT, LIC.NO. MECH.
TOTAL TOTAL /
Sign App icon[/ ontmet Date
INSPECTOR COPY